This patient presented to my office in Burbank by referral for dental implants from another patient. She had two dental problems. One was her 6 tooth front upper bridge was loose and had come out a few times and the second problem was her lower molar in the #19 position.
After examining her, it was noted that the 6 unit anterior bridge was only anchored by the two canine teeth. Both of those teeth had root canals and had broken off to the gumline. They are too weak to use for a new bridge. In this space where she had been missing the four center upper teeth (7-10) her bone had atrophied (shrunk) because the teeth have been missing for so long.
On the bottom jaw, her existing molar was cut in half by her previous dentist and a root canal was done through a very old procedure called a hemisection. She was walking around with basically half a tooth that wasn’t even re-crowned because of its poor prognosis. The complicating factor on the lower jaw was that she had an impacted premolar tooth stuck deeply in her jawbone. She was told an implant could not be done here because the impacted tooth was in the way. Generally speaking impacted teeth can be removed like wisdom teeth are impacted. This tooth is special because it is completely encased in bone and has a very high risk of nerve damage and jaw fracture to remove it.
In order to treat her in both the upper front and lower left #19 area several procedures in sequence were necessary. Her treatment took about 11 months to complete.
5 Steps to Successful Treatment
Tooth #19 molar would be extracted at the same time as this procedure under IV sedation anesthesia.
I made her a temporary removable partial denture stayplate (some people call this a “flipper”) to be used as a temporary that was inserted on the same day of extraction and bone grafting.
2. After waiting 4 months for the bone graft for the upper front teeth to become strong bone , 3 implants were placed into the newly widened bone in the upper front area. At the same time, under sedation, a purposely tilted implant was angulated around the impacted premolar tooth.
The tip of the implant would be placed at an angle so that it would not hit the impacted tooth but the head of the implant would come out in a more ideal location for the molar.
3. The implants were allowed to heal for 4 months after placement.
4. A custom abutment was made for the angulated tilted implant in the #19 molar position. Custom abutments were also made for the 3 front implants so that their angle could be corrected and to be tall enough to support a bridge.
Custom abutments are able to correct angulation when implants are purposely placed in tilted positions such as the all on 4 procedure
5. The molar was replaced with a monolithic zirconia crown while the front bridge was custom fabricated from porcelain fused to metal with gum colored ceramic. Pink tissue porcelain was used so that the teeth would not look too long.
The pink porcelain edge does not show when she smiles, so no one can tell that both white and pink porcelain was used to make her smile looks much more natural. Both of these bridges are held by cement rather than by screws.
Keep in mind that her situation is compromised to begin with so a perfect result is not possible. She has an overbite from her upper jaw being too big which will always compromise the cosmetics of the front teeth. She is a very sweet woman in her 60s that just needed a healthy, confident smile that she would not have to worry about any more.
Every Dental Implant Case is Different
I think it is important to show cases to you that are real in every day dental practice. Nature made us all very unique and that is beautiful thing. If you have a unique case, and would like a second opinion, please contact our office and schedule your appointment.
Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry