Dr James Hamill presents an implant case requiring an upper and lower complete approach using the Chrome Guidedsmile solution from Quoris 3D
This 69-year-old female patient first presented on 4 February 2020 to Radiant Dental Practice in Northern Ireland, having been referred by Cavan-based clinical dental technician, Garrett MacEnri.
The patient’s medical history revealed that she was taking medication for high blood pressure and anxiety, and that she was a non-smoker.
Her dental history indicated that she was dental phobic, specifically in relation to needles.
This was the result of a number of traumatic dental experiences in her youth, leaving her distrustful and highly anxious when it came to dental treatment.
She had been an intermittent dental attendee for over 50 years, presenting only when in pain.
The patient reported that, since retiring as a medical nurse, she had been building up the courage to ‘sort out her teeth’.
She was suffering increasing anxiety about her dental appearance and reported that this had been a lifelong concern, to the point of being debilitating during social and personal interactions.
Pain had been a daily experience for her for over 50 years due to her traumatic occlusion and she was now determined to address this issue.
Finally, function was poor, with her wearing an ill-fitting and uncomfortable denture.
Therefore, her motivations to seek treatment were appearance, comfort and function, with an overarching wish to improve her confidence and health.
The dental examination
The initial dental examination revealed a partially dentate patient.
Her oral health was fair to good with high levels of patient motivation, but clearly there had been a history of poor oral care and periodontal disease with generalised moderate to severe gingival recession.
She had suffered maxillary tooth loss with resultant bilateral hard and soft tissue defects in both vertical and horizontal dimensions, resulting in mobility of the remaining teeth which were in a poor restorative position.
The lower anteriors were assessed as grade 3 mobile with periodontal involvement.
Dentition loss had been the result of a combination of periodontal breakdown and tooth tissue breakdown due to decay and neglect in the past.
Overall, the patient had:
• Over-eruption of molar and incisor teeth
• An ill-fitting upper acrylic partial denture
• Deep traumatic overbite
• Generalised mobility, grade 2-3
• Lack of posterior support
• Loss of vertical stop
• Loss of facial support
• Decrease in lower face height.
Following the assessment, an OPG was taken and treatment aims discussed, with:
• To correct traumatic occlusion
• To re-establish lower face height within normal and acceptable limits
• Improve function
• Eliminate pain
• Improve appearance and confidence
• Provide a fixed prosthetic result (get rid of the denture).
After the clinical and initial radiographic assessment, it became clear that this case would require an upper and lower complete approach.
There were a number of possible treatment options open to us, as follows:
• Removal of hopeless teeth and restoration with removable prosthesis
• Removal of hopeless teeth, placement of implants and restoration with removable implant-supported/retained prosthesis
• Removal of hopeless teeth, placement of implants and restoration with fixed prosthesis using a delayed/conventional approach
• Removal of remaining dentition, placement of immediate implants, immediate provisional bridges and restoration with fixed full-arch bridgework using a non-guided approach
• Removal of remaining dentition, placement of immediate implants, immediate provisional bridges and final restoration with fixed full-arch bridgework using a fully guided approach.
Following discussion with the patient and having established that her wish was for a fixed restoration of the highest quality the various options were considered, and it was established that there was a reasonably high expectation of treatment quality and success.
Being somewhat time poor and having to travel quite a distance for treatment, there was a desire for as few appointments as possible.
It was decided that, due to the minimal number of lower teeth that could be deemed salvageable and the degree of repositioning required due to over-eruption and bone loss, a full clearance was justified.
Having discussed all the issues and options with the patient, it was concluded that the best solution to manage the time, accuracy, high level of planning required, quality of result expected, and the challenging clinical situation was to use the Chrome Guidedsmile solution from Quoris 3D.
The patient journey
The initial consultation and conversation took place chairside and lasted an hour.
Next came an appointment for record-taking: photos, impressions and CBCT, which was another 45 minutes chairside.
The initial records were sent to Quoris 3D for evaluation and a JC try-in was advised.
This was agreed with the patient and so a pre-planning appointment was set up for the JC try-in, to establish the new vertical position.
Again, this was 45 minutes chairside and the new record sent to Quoris 3D.
It was then possible to create the final treatment planning letters for the Chrome Guidedsmile technique. Costs were confirmed and agreed remotely.
Just 10 days after the JC try-in was sent in, there was an online planning meeting with CHROME designer, Liz Goss, which lasted 45 minutes.
Here the case was discussed in detail and final restorative and surgical parameters agreed upon.
Things were delayed by the COVID-19 lockdown (the initial surgery was scheduled for 26 March 2020) but, on 5 August, the double-arch Chrome surgery carried out, which lasted four hours.
After another two weeks, the sutures were removed, which was 30 minutes chairside.
The situation was reviewed in the practice on 4 November, lasting 30 minutes.
This was followed by the RAPID transfer visit on 2 December and the final fitting of the bridge on 7 January 2021, each of which took 45 minutes.
In total, the treatment time was nine hours and 45 minutes, including one online meeting.
The patient was very happy with the outcome, and left the practice smiling and with a new spring in her step.
In clinical terms, a great outcome was achieved both in terms of form and function, in not the easiest of circumstances, including but not limited to the global pandemic and overcoming the patient’s understandable anxiety.