Dental Implant Strategy - No Removable Temps

When we do dental implant treatment, and especially when we combine it with comprehensive rehabs, the temps can often be tricky.

Today, I am going to walk you through an interesting case that I had, and how we decided on the treatment strategy. 

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This is our situation: He is having a full smile done, but I am only doing the implant work for him, and a referring dentist is carrying out the restorative work. 

Because I do a lot of restorative myself, I understand how to make it easy for another dentist to get great results. 

The overall plan is to place dental implants in the UL2,3 and 5 positions, then we will make a bridge that connects it all up. 

If it was totally up to me; I would remove all the teeth and place implants, do a CTG - but leave them unloaded. 

Unfortunately, this would leave the patient with no visible teeth during the healing. 

Although they don't look that great at the moment, he doesn't want to make them look worse! 

So that plan is out of the window. 

Another option might be to make a temp bridge and load all three immediately. I mean, we do all on 4 right, and Nobel have a kind of all on 3 full arch solution. It might be fine?!

But he has a deep bite, and posterior support isn't that great. It might work, but what if he bites on the bridge by accident? What if it breaks? 

We could lose the implants, and start again. 

If we lose the implants, then we lose our gum margins, and things get tricky from a cosmetic angle. 

I felt that risk was a bit too high. 

One aspect that I should mention is that I like the shape of the gingival margin. Yes we can refine them a bit, but placing the implants immediately will let us preserve these... So I am thinking, lets try and preserve and place immediately. 

Okay, back to the case, lets think of another strategy...

We need fixed temps. We also need immediate implants, with low risk. 

The option that I came up with was a compromise on clinical time (so it costs me more) - but it was the right thing to tick all the clinical and patient requirements. 

I removed the UL3 and UL5, and placed dental implants in those positions. With a little bone grafting, you know, the normal process for immediate dental implant placement, and I put temp cylinders on these implants. 

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We kept the (terrible) UL2 and 4, as these would hold our temp bridge. 

To support the shape of the gingivae, I made a custom healing abutment on the cylinders. 

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Now, as these were single units, I believe (I cannot remember), the cylinders would have been indexed... which may cause a problem later... But we will come to that. 

Now, to satisfy the patient's need for fixed temps, we can use the UL2 and 4 to fabricate some kind of bridge / hovering veneer (yes, I just made that term up)

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I could have extended the bridge to the 6 (as this needs a crown) but that would add another failure point, and even if a 5 breaks, patients will call us to have it repaired. 

Also, he is leaving with a better smile (more visible teeth) than where he started! 

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I made sure that the temp abutments had space all around them, so that he was able to clean them. 

Obviously, check the occlusion to make sure there are no high spots or guidance interferences.

In regards to the temporary bridge; I should mention that we make the temps freehand, and it's done at the beginning of the appointment, before blood. 

That way the powder of the temps (from adjustment) does not contaminate the wounds. 

And, after the surgery, when you are shattered - all you need to do is slot the temps into position! 

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The next phase was supposed to be yesterday, but our autoclave failed, so we have rescheduled it for a few weeks. 

But, what we will do is remove the other teeth, place the implants into the UL2 position, and use our two (now integrated) implants to make a bridge. 

This is where the indexing may be an issue. Even though the implants are quite parallel, if both cylinders are indexed, then placing and removing the bridge will be very difficult. So I may need to replace one cylinder to be non indexed. 

Not a big deal - just something I need to be prepared for! 

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