Here is an interesting full double arch dental implant case that I took over from another dentist. This patient desired full mouth dental implants. When he presented to my office he already had 10 implants but could not use his teeth. He paid a lot of money only to be disappointed with the removable over dentures that were made for him.
You can see on the preoperative x-ray that he had 6 upper dental implants and only all on 4 lower dental implants.
The implants were mostly well placed from a spacing standpoint and might have been able to be used for fixed dental implants such as a Prettau zirconia full mouth dental implant bridge. Rather than having a fixed bridge or an all on 4 fixed bridge, the dentist chose to make an overdenture!!
The overdentures never worked for him.
They were way too bulky and had a tremendous thick pink area we call a flange. The crazy thing is that there is no way overdentures could have ever worked because all the implants were placed way too shallow! In order to have overdentures, you must have enough room from top to bottom (inter-arch space) to fit the dentures and plastic abutment attachments that make them snap into place. The gold attachments are called locator abutments which typically work well on the lower jaw only.
He never wanted to have removable teeth but that is NOT what he got. He was not able to wear the overdentures at all and came to me for a better solution. He had gone 3 years like this. The teeth were even made twice and then he gave up. He told me I was his last hope.
After evaluating him carefully I determined that the implants were placed in a shallow position more ideal for “regular implants.” We refer to this in dentistry as an “Fp1” prosthesis. That means there is no reason or room for the pink portion which most patients need because they are missing bone and gum. This patient actually had excessive bone which is very rare and in retrospect if he really wanted an overdenture should’ve had a bone leveling alveoloplasty procedure.
This very well could have been a communication problem between the restorative, tooth making dentist, and the implant surgeon. In this case, there were 2 different people who started the procedure. I am a strong believer that these complex dental implant procedures should be done from start to finish with a *single* skilled provider or a very tightly connected and experienced partnership duo.
The upper implants unfortunately were all squished in the front, without any dental implants in the molar back tooth positions with minimal inter-arch space. On the lower jaw they were well spaced but there was too much space between implants for the regular/crown and bridge/Fp1 type teeth.
The solution was to add four additional implants into the molar regions on the upper with some simple internal sinus lifting. On the lower jaw I added 3 implants in strategic locations to shorten the spans of the bridges. If the span is too long, and the zirconia material is not thick enough, the teeth will break…yikes!!!! The additional implants will support the material. This will allow him to have basically regular teeth back again without any of the pink porcelain or pink plastic.
In a single appointment, I added these additional 7 implants with minor sinus grafting under IV sedation at my office in Burbank, California. The implants were allowed to heal for approximately 4 months prior to starting the restorative process.
Fabricating his teeth was very complex because of 2 different implant systems and at least 4 different proprietary screwdrivers and parts. The locator abutments also had a very narrow “sulcus” which would be too small at the tooth neck for regular size teeth. I actually had to custom alter make all of the special titanium implant impression transfers to fit into the overly narrow gum channels.
A verification jig was 3D print milled to be certain that all 17 implants had a very accurate impression so that there is no misfit of the new teeth. I also created a screw retained wax rim teeth in order to select tooth size, color, position, bite level and a host of other factors.
In these photographs what you are seeing is a temporary PMMA double arch bridge. This is not the final although it may look like a final bridge!
All teeth were designed using 3-D 3shape software. I had my very skilled lab technician digitally create wider gum channels so the teeth at the neck appeared more of a normal size so they would not have mushroomed stalks. At the delivery appointment for the temporaries I had to surgically open his gums to fit the teeth. This will allow any papilla or gum triangles to fill in as needed and “groom the gum tissue” to fit the new teeth. The PMMA is a milled plastic/acrylic material so the bite can be adjusted and refined. I will then take all of this information and translate that to the final restoration.
I usually allow my patients to wear the screw retained PMMA full fixed implant temporary bridge for a few weeks to a few months depending on how much testing and adapting the patient needs. Some people adapt very quickly with speech while others need a bit more time to learn where there teeth are in space. This testing duration also allows the TMJ jaw joints an adaptation period. Also the bone can progressively be given bite strength with this softer material and gradually get to the solid monolithic zirconia restorations.
Sorry for the blood in some of the photos as they were taken on the day of surgical delivery of these temporary restorations. The finals will look very similar to this except even better 🙂
I hope this explain some of the highly complex procedures that go into recovering such a difficult situation. Unfortunately a lot of what I do nowadays is correcting and redoing bad situations which could’ve been done right the first time with better planning.
Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry