Dr. KRIS LEESON
Dr. Kris Leeson BChD MJDF MSc (Implant dentistry) PGCert (Health Care Ed) graduated from Leeds University in 2005. An award-winning dentist, he is also a member of the Faculty of Dental Surgery of the Royal College of Surgeons of England and has achieved a Master’s in Implant Dentistry, from Warwick University. He offers a full range of dental implant solutions, from the simple to the very complex. Kris has been involved in digital dentistry for ten years, using digital solutions for nearly all his dentistry.
Double-arch implant reconstruction using CHROME
Dr Kris Leeson presents an implant case requiring an upper and lower complete approach using the CHROME GuidedSmile solution from Quoris 3D.
This 56-year-old male patient first presented on 8 July 2020 to Thorpe Dental Implant Centre, having been referred nternally because he had expressed concern about his teeth wearing down and his aesthetic appearance.
Upon examination, the patient’s medical history was impeccable with only a reported allergy to pineapple. However, his dental history indicated a significant amount of historical dental treatment, along with spacing resulting from missing teeth and a traumatic injury whilstplaying rugby. His dentition was very heavily restored, especially posteriorly.
His upper and lower dentition showed signs ofsevere wear, with the LL5 suffering from apicalpathology and the LR4 needed a pulp extirpatedue to exposure of the pulp chamber.
He was wearing a partial denture in the upperarch and nothing on the lower. Due to a lack of posterior dentition on the lower, the uppermolars had over-erupted and, as a result of the trauma at UL1 and UL2, he presented with a significant alveolar defect.
His periodontal condition was low with noperiodontal pocketing and excellent oralhygiene. The very worn lower incisors were all non-vital to cold stimulus and the electric pulptest.
Nonetheless, the long-term prognosis of the lower dentition was poor.
Following the assessment, a CT was taken, and treatment aims discussed. They were:
- To re-establish lower face height within normal and acceptable limits
- Improve function
- Eliminate infection
- Improve appearance and confidence
- Provide a fixed prosthetic result. Following the clinical and initial radio graphic 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 a removable prosthesis
- Restore the lower dentition following root canal treatment of nonvital teeth, with full coverage crowns +/- implants or partial dentures to restore the edentulous spaces
- Removal of hopeless teeth, placement of implants and restoration with a removable implant-supported / retained prosthesis Removal of hopeless teeth, placement of implants and restoration with a fixed prosthesis using a delayed / conventional 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 his wish was for a fixed restoration of the highest quality, it was established that there was a reasonably high expectation of treatment quality and success.
The decision to remove all the remaining dentition was finally made due to the poor long term prognosis of the very worn teeth and the poor position of the upper molars.
At the beginning, it was hoped treatment could have been completed with just a fixed prosthesis (FP1) to replace the missing teeth. However, due the significant alveolar defect, it was decided the best approach was an FP3(essentially, replacing missing crowns and addressing the gingival colour and portion of the edentulous site).
As a result of the excellent bone volume, it was initially decided that 6 implants would be placed upper and lower.
Having discussed all the issues and options with the patient, it was concluded that the bests olution to manage the time, accuracy, high level of planning required, and quality of result expected, would be to use a guided approach with immediate implant placement and restoration.
Figure 1: The iTero scan shows the extent of the wear and exposure of the pulp chamber at LR4
Figure 2: The anterior frontal view demonstrates the alveolar defect and the limited posterior dentition
Figure 3: Full-face smiling image displays the moderately high smile line and reduced vertical dimensions
Figure 4: Dental simulation
Figures 5, 6 and 7: Extraction of the teeth, placement of 12 dental implants and restored within 4 hours
Figures 8 and 9: Fit of the provisionals was uneventful and access holes were filled with silicone to allow for easy removal if needed
Figure 10: OPG taken after treatment showing ideal position of dental implants
Figures 12 and 13: Provisionals removed after three months
Figures 14 and 15: The end result
The provisional restorations were kept in place for 3 months. The patient did have areas of severe wear, but they remained intact. Figures 12 and 13 show the first time the provisionals were removed, exhibiting great soft tissue. The erythema of the soft tissue will improve when the final prosthesis is fitted, and the patient maintains better oral hygiene.
After 3 months, a RAPID appliance was used to record the occlusion and mark centre lines, etc. The RAPID appliance was a copy of the provisional and was picked up at the same time as the provisional. The RAPID appliance was also used to take the final impression; a shade was taken, and the RAPID appliance sent to aid construction of the final prosthesis. Due to the patient’s bruxism and parafunction, it was decided that we would complete both bridges in zirconia.
When the patient was reviewed at 6 months, he reported no problems and was maintaining a good level of oral hygiene. The bridges were removed, showing improvement in soft tissue appearance. At the time, the bridges were steam cleaned and replaced, and the access holes restored with Teflon, to cover the screw and composite.
To maintain these appliances and the dental implants, the patient was advised to see a dental hygienist on a regular basis. For professional and at-home care I recommended:
- 3/12 hygiene appointments
- Oral hygiene using X-Floss and a water pick
- Night wear of a lower soft bite splint
- Occasionally, the bridges are to be removed and steam cleaned, with removal of any calculus deposits. The regularity of this is on a case-by-case basis.
This patient’s situation presented a number of interesting challenges, however, by using CHROME GuidedSmile we were able to achieve a very good outcome and sent away a smiling patient!
Overall, the patient had:
- Over-eruption of the upper molars
- An ill-fitting upper acrylic partial denture
- Generalised wear with severe wear of the lower incisors
- Lack of posterior support
- Loss of vertical stop
- Decrease in lower face height.
CHROME, available exclusively through Quoris 3D in the UK and Ireland, offerspioneering full-arch stackable guide technology and was developed for dentistswho desire a pre-planned, predictable guided ‘All-On-X’ type of surgery.
In its entirety, the CHROME service delivers anchored bite verification, anchoredbone reduction, anchored site drilling, accurate anchored provisionalisation, and amethod of transferring all surgical and restorative information for the finalrestorative conversion phase.