PMC6975014_01
(a) Anterior view, (b) maxillary occlusal view, (c) mandibular occlusal view, (d) right lateral view
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F1
A 38-year-old female patient reported to the Department of Prosthodontics with the complaint of broken anterior teeth [Figure 1a]. Her maxillary arch contained all teeth except the third molars and the right first premolar, while the mandibular arch was devoid of molars on both sides and premolars on the left side [Figure 1b and c]. The edentulous span in the lower arch on the right side had resulted in supraeruption of the opposing dentoalveolar segment consisting of teeth 15, 16 and 17, leading to complete absence of restorational space on the lower arch [Figure 1d].
(a) Left lateral view, (b) computed tomography scan showing upper arch, (c) computed tomography scan showing lower arch, (d) computed tomography scan showing the narrow alveolar bone width of the lower-right arch
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F2
However, supraeruption of the left maxillary posterior dentoalveolar segment had not occurred [Figure 2a]. A computed tomography scan was obtained to assess the periodontal and endodontic status of 15, 16, and 17 and the alveolar bone height and width of the corresponding mandibular edentulous span [Figure 2b-d].
(a) Articulated diagnostic casts (right side) showing the mock surgery in the maxilla and acrylic tooth (46) on the lower arch, (b) articulated diagnostic casts (left side) showing acrylic teeth (34, 35, and 36) on the lower arch, (c) buccal full-thickness flap raised, (d) horizontal osteotomy
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F3
A mock surgery was carried out on the upper cast by cutting and lifting up the entire right posterior segment along with teeth to assess the amount of segmental osteotomy necessary to accommodate an implant-supported prosthesis in the lower-right edentulous region [Figure 3a and b]. Under general anesthesia, after administering local anesthesia, a buccal full-thickness flap was raised [Figure 3c]. Horizontal osteotomy was performed from the second premolar till the maxillary tuberosity, on the right side [Figure 3d].
(a) Fixation with plates and screws after segmental osteotomy, (b) sutures placed after segmental osteotomy, (c) root canal impressions made with pattern resin, (d) cast metal posts and cores cemented
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F4
The maxillary posterior segment was then separated and shifted as planned and was fixed using plates and screws [Figure 4a]. Intraoral resorbable vicryl sutures [Figure 4b] were placed and intermaxillary fixation was carried out. Root canal impressions were made with pattern resin, using the direct technique [Figure 4c]. Cast metal posts and cores were then fabricated and cemented [Figure 4d], followed by temporary crown placement over 11 and 21 [Figure 5a].
(a) Temporary crown placement, (b) ridge-split procedure using micro-saw, (c) Implant placement, (d) tooth preparation in the upper arch
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F5
Cast metal posts and cores were then fabricated and cemented [Figure 4d], followed by temporary crown placement over 11 and 21 [Figure 5a]. A ridge-split procedure using micro-saw and ridge expanders (Esset kit; Ostem) had to be performed since the width of the alveolar ridge was found to be inadequate [Figure 5b]. Implant placement was done in place of 34, 36, and 46 [Figure 5c]. In the upper arch, tooth preparation was carried out for 16, 15, 13, 12, 11, 21, and 22 to receive PFM crowns [Figure 5d].
(a) Tooth preparation in the lower arch, (b) final impressions of both arches made using addition silicone, (c) porcelain fused to metal crowns cemented (anterior view), (d) porcelain fused to metal crowns cemented (right lateral view)
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F6
PFM crowns [Figure 6a], final abutment level impressions for both the arches were made using Aquasil (Dentsply) addition silicone [Figure 6b]. PFM crowns were fabricated and cemented [Figures 6c, d and 7a], and a posttreatment orthopantomograph was obtained [Figure 7b].
(a) Porcelain fused to metal crowns cemented (left lateral view), (b) posttreatment orthopantomograph
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F7
PFM crowns [Figure 6a], final abutment level impressions for both the arches were made using Aquasil (Dentsply) addition silicone [Figure 6b]. PFM crowns were fabricated and cemented [Figures 6c, d and 7a], and a posttreatment orthopantomograph was obtained [Figure 7b].