Case 25 | Prosthodontic Award 2015 | United Kingdom
Dr. Federico Brunner | DT Petr Mysicka
This 41 years old female patient came to me last year, she told me that she was involved in an car accident about 15 years ago, that accident did not only just broken several bones in her body, it had also wiped her smile away from her face, almost all her teeth were badly broken, she went to the dentist and started to have many treatments done: Root Canals,fillings,crowns and bridges etc,many of her teeth have been removed.Eversince then, she fell very unconfident of her teeth and smiling in front of people.
She is medically healthy, none smoker and had no periodontal problems.
In the past couple of years, she started her searching, for a dentist whom is willing to help her to restore her smile and confident. She wanted to replace all the missing teeth and improve the appearances of her smile. She told me that many dentists she has visited in the past, suggested to her to have all her teeth removed and then full rehabilitated with dental implants.
Due to the complexity of her case, and because she wanted to improve and change her smile, I decided to choose and follow the DSD protocol to study her case in depth. I explained her that after the DSD, I will provide her with the treatment plan. In this case was very evident that the gummy smile needs to be considered, also having in mind that I would need to shorten the incisor’s edge, and correct the position of them. I did my first design.
It was obvious from the beginning that mock up was impossible in this case, but I wanted to check if my design was going in the right direction before I start. I wanted to show her what I would like to achieve before we start, so the idea of ‘snap on removable veneers’ came into my mind, I tried my design first, this has started my brainstorming process. When I showed her the photos, she said she likes what she saw and wants to go ahead and continue with the planning process.
After the “playing with visual effects” appointment, we mounted models in the articulator and prepared first provisional. I explained to patient that for me to be able to accurate the diagnosis, and give her an estimate, I would need to remove the old restorations and see how the remaining teeth were underneath, patient agreed.
I removed the old restorations (bridges), I decided to conserve the front teeth until I finish the case. I explained to her that the prognosis of the upper front teeth were uncertain, but was very important to try to conserve them as much as we can at least until we finish the case,and the occlusal and aesthetic parameters would be achieved.
Osteotomy was done in the same appointment when I removed the old restorations and first provisional was placed, at end of the treatment , there was no need for gingivectomy.
10 days later, I placed the second provisional and then third provisional 3 months later, the 4 th provisional was placed 8 months later.
In the meantime, I placed implants to replace all the missing teeth. Once implants were healed, I loaded them with provisionals in order to get the new function (bite). Vertical dimension was almost conserved, there were no major changes.
Once all the parameters were achieved (bite, vertical dimension, gum profile, smile design etc), patient was satisfied with the aesthetic outcome, I took the impressions to copy exactly what we have achieved before, no changes were made.
Due to the complexity of this case, between every provisional, I have used and followed DSD photo protocol to ensure quality control of the design, and this helped me to reduce the corrections and adjustments to the minimum, to achieve the accurate design throughout the treatment, from beginning to finish.
Patient was pleased with the final result, she said this whole experience has changed her life and put big smile back on her face, she found her confidence said she will never hide her teeth again when she smiles.