A permanent smile solution
This article describes the restoration of a fully edentulous upper arch. The patient had been edentulous for more than 30 years on the upper jaw. The lower jaw was fully-functional and, although some teeth were missing, was in good health.
The patient requested an appointment to discuss the possibility of having her upper denture replaced using dental implants. She was finding that, with the passage of time, her upper jaw was becoming increasingly atrophic, her denture was becoming increasingly unstable and she was concerned about its long-term prognosis.
A long period of discussion ensued, during which the patient explored various treatment options. The first option was to do nothing. However, the patient was concerned that in a few years she may not be able to wear her upper denture at all because, with continued atrophy of the maxilla, there would be little or no retention.
The second option involved placing two or three implants – if sufficient primary stability could be found – and subsequent retention using locator abutments and ring retainers inserted in the denture. The third option was to carry out bilateral sinus grafts and optimally place the implants away from the resorbed anterior maxilla, so that a full mouth rehabilitation could be carried out.
The patient was given information on this procedure and the invasive nature of the surgery involved. Also discussed at length were the risks, including the possibility of post-operative infection, the small risk of an oro-antral fistula if healing did not progress well and the possibility of failure of the graft to integrate. The possibility of facial bruising in the weeks following the procedure was also discussed.
The radiograph in Figure 1 shows the preoperative maxilla with thin antral walls and much resorbtion of the premaxilla. A ridge map of this area showed there was only thin fibrous tissue insufficient for implant fixtures.
Fig 2 shows the patient’s denture. It was relined with Fuji soft tissue conditioner several times during the treatment.
The patient finally decided that she wished to progress with the treatment programme, placing implants in each grafted sinus.
The patient was sedated using Midazolam and the right maxillary sinus was accessed using a lateral window utilising a technique first described by Hilt Tatum. The sinus membrane was lifted intact, a Bio-Oss collagen membrane then inserted below the raised sinus to protect the elevated sinus lining, and four Ankylos 11mm implants were inserted through the floor of the antrum such that good primary stability was achieved. Supplementary allograft was then compressed around the implants and the lateral window closed by tacking a Bio-Guide collagen membrane over the opening. The flap was then closed. This procedure was repeated approximately one month later on the opposite side.
The denture was relined with a soft lining and the patient was dismissed for six months (Fig 3).
The healing period for the sinus grafts went well, with no complaint from the patient and she returned after a period of about six months to begin the restorative phase of her treatment. Healing caps were placed and it was noted that all the implants seemed to be well osseointegrated.
The healing caps were left in place for about one month, allowing the gingival margins to form above the implants (Fig 4). After about one month, an open tray impression was taken of the full arch using a customised special tray (Fig 5). This impression was sent to the laboratory so that abutments could be placed and modified as necessary and a metal casting returned for try-in or modification (Figs 6-8).
The metalwork and the abutments were then returned to the laboratory, the prescription being to make the bridge in composite rather than ceramic so that minor repairs and adjustments could be facilitated. In this case the laboratory used Gradia, which has a high ceramic particle content but can be bonded to with relative ease. Lateral fixation screws (Bredent) were also prescribed so that if necessary the whole prosthesis could be removed for cleaning or for minor maintenance (Fig 9).
The prosthesis was tried in again on return from the laboratory, however the lateral fixation screws proved quite difficult to insert. This was attributed to the jigs not having lateral screws through them and so allowing for a small lateral orientation error to creep in – there being no indexation used in this case (Figs 10, 11).
I was reasonably pleased with the outcome of this case (Fig 12). I feel I have overcome some big hurdles and achieved what I hope will be a lifelong improvement in this patient’s dentition. On the day I was writing this up, the patient sent in her testimonial (see below), which provides quite a different perspective in terms of the aspects of the treatment that she found difficult (placing the healing caps) and those that she felt she managed well (the sinus grafts).
Dr Eilert Eilertsen, BDS UDUND 1976, Eilertsen Dental Care in Inverness.
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The implant patient’s perspective
Having had an upper denture (the result of botched dental treatment following a playground injury that damaged my teeth) since I was a teenager, I expected to have one till my Maker called me home. So, when Dr Eilertsen first suggested bone grafts and dental implants as the most effective way to deal with severe upper jaw bone loss and potential problems with denture retention, I was a bit stunned and not a little scared.
However, he explained the procedure – its benefits and risks – and, after a period of due reflection, I decided to go ahead with the treatment.
After the first session, I had no unpleasant after-effects, other than a bit of vague aching. However, a few hours after the second surgery I experienced about 20 minutes of excruciating pain that came in surges, and made me scream out in agony. There was no evidence of bleeding or anything being amiss and, after a telephone consultation with Dr Eilertsen during which the pain subsided, we decided an emergency visit to the surgery wasn’t necessary.
Dr Eilertsen believed that the pain could have been caused by the small blood vessels opening up rather suddenly as the anaesthetic wore off. I also experienced some bruising on my cheeks some days after both sessions of surgery, which persisted for about two weeks.
After six months of waiting for the grafts to ‘take’, the next stage was fitting the healing caps. I actually found this the hardest stage in terms of discomfort/pain and inconvenience. The small openings in the gum were made under local anaesthetic and did not hurt, but the bone graft had been so successful that the bone had already grown over the ends of the implants and had to be removed before the caps could be fitted. This involved a lot of pushing, scraping and general heaving around in my mouth, and left me with aching jaws for several days. Also, once the local anaesthetic had worn off, the action of the healing caps to shape the gum at the ends of the implants caused considerable pain for several days.
I removed my denture to clean it, and could not get it back in, leaving me toothless for a few days. Fortunately I’m self-employed and it was the weekend, so I simply stayed in until I could get an appointment with Dr Eilertsen. By that time the healing was well under way and the pain gone, so he relined the denture, put it in for me, and I was able eat and speak more easily again. Social life was still much curtailed though, because I was pretty desperate to remove the lined denture by late afternoon.
At last the big day came, and the prosthesis clamped on perfectly and felt remarkably natural, with the exception of one tooth at the back, which Dr Eilertsen adjusted. I am now at the stage of learning to adapt how I eat, speak and use my jaws with this new structure in my mouth. At present, I tend to bite both my tongue and my cheeks, and my neck aches, I think because I am using different muscles to move my tongue as I learn to accommodate the prosthesis. Dr Eilertsen said this process might take as long as three months. It is tiring making this adjustment, and particularly so when this learning process is on top of nine months of treatment that was also a strain in various ways.
So, in conclusion, I am delighted with the final outcome, at this stage certainly, and my delight grows every day. I have every confidence that it will soon feel as natural as any other part of my body. Family and friends say it looks very good and my husband says it has made me look more youthful around the mouth, so that’s an added bonus!