Prosthodontics deals not only with reconstructing the missing teeth, but also with the aesthetic correction of the remaining teeth and with improving oral occlusion. Patients often think of the prosthetic phase as a key stage. We need to remember that prosthetic treatment often requires preparation treatment. Reconstructive procedures of prosthetic base tissue, periodontal treatment, orthodontic treatment, conservative treatment with endodontics are often the initial phase, which will only culminate in reconstruction of the missing teeth.
Significant atrophy of the alveolar bone in the vertical and buccal-palatal dimension. Without proper preparation of the prosthetic base, correct bridge placement is not possible. The patient complained of a strange shape of the teeth in the old bridge and retention of food over the span of the bridge. The treatment started with removing the old bridge and bone augmentation procedure. After the reconstruction of keratinized gums a new all-ceramic bridge was placed. Retention of food disappeared, there is no bleeding, and the patient has a nice tooth shape, which is important with high smile line. There are two more procedures planned: a bone regeneration surgery and a new all-ceramic bridge on the left side.
A similar situation, but this time in the mandible. Before the prosthetic phase it was advisable to prepare the prosthetic base first. In this case soft tissue microsurgery was enough to achieve satisfactory result.
The patient complained of swollen soft tissues adjacent to the bridge, retention of food, and bleeding gums. The three-year-old bridge was removed. The abutment tooth had extensive decay from the palatal side. There was also a significant loss of alveolar bone volume and lack of keratinizing gum under the bridge span. The missing alveolar tissue was rebuilt and after 3 months a new bridge was made. The results satisfy the patient.
We often encounter big discrepancies between the expectations of patients, who ask when their new teeth would arrive or when they would have a nice smile. Sometimes we also meet patients who attempt to control the treatment process, as per their awareness and expectations. It is a big challenge. Patients sometimes ask: "Please do not treat the root canals again. They don’t bother me. It doesn’t hurt at all." When there is a recommendation for tooth extraction (for example due to extensive destruction of hard tooth tissue, or lesions of the tissue surrounding the tooth), patients expect that hiding the tooth under the crown will solve the problem. Patients think that if the tooth is saved they will avoid extraction. Unfortunately, this is not proper treatment. It should be strongly emphasized that preparation treatment, including sometimes lengthy and laborious procedures is absolutely necessary.
Often there is a need for treatment on both jaws. The patient wanted to have a bridge placed in the mandible (upper jaw). He was not interested in prosthetic treatment in the mandible. He was not bothered with the lack of rear, side and lower teeth. Finally, the patient agreed to treat both jaws. Vertical dimension of occlusion was restored. Facial features have changed significantly.
Occasionally, patients with extensive number of teeth missing need temporary prosthetic work done, especially those patients with severe occlusion defects (the alignment of dental arches), and dental muscle and joint problems. Such procedure prolongs the whole treatment, increases the costs, but it is the only complete and correct therapeutic process in this case. Our bite is stabilized at the front by contacts of the upper and lower dental arch, and at the back by the temporomandibular joints. For each prosthetic solution where there is no stable position of dental arches against each other or there is lack of stable central relation, the use of a facebow is required. It is the only safe method of transferring the prosthetic plane of the upper dental arch relative to the base of the skull. This results in optimization of the position of dental arches relative to the temporomandibular joint, and the correct setting of mandible heads in condylar joints.
The patient complained of some problems with the temporomandibular joint. Previous prosthetic treatment was performed without aligning the occlusal plane. The old bridges were removed, endodontic treatment followed and the stumps of the abutment teeth were rebuilt. Then the clinical crowns of teeth 24 and 25 were elongated and keratinised gum was restored under the span of the lower bridge. The new bridges for upper and lower dental arch were made only in the last stage. A significant improvement was achieved, especially in the functioning of temporomandibular joint. The symptoms were alleviated.
Preparing abutment teeth stumps plays an important role in prosthetic preparations. It may seem simple when we can limit to the reconstruction of supragingival part of the stump. When damage is also present below the gingival attachment, we have to deal with much more difficult situation.
The following photos show a difficult periodontal case. In case of extraction of tooth 47, the patient will lose a chance to have a bridge placed. For anatomical and financial reasons implants cannot be used either. After root canal treatment the stump of tooth 48 was restored. The right technique of reconstruction needs to be selected. The composite materials cannot be pushed into the gingival attachments. Then the abutment teeth were contour ground. The patient had high aesthetic demands; therefore, an all-ceramic bridge was placed.
The patient fractured the buccal side of his tooth. The fracture line reached about 3 mm below the gingival attachment. An attempt was made to save the tooth by lengthening the clinical crown. After the surgery, the patient was provided with a temporary prosthetic solution. The final crown was made six months after the surgery.
Proper determining the occlusal plane and the mutual position of dental arches is of paramount importance. Here are the before and after photos of the patient who had her dental arches aligned and their shapes corrected. The difference is visible.
At the age of 89 the patient was in need of some prosthetic treatment. The old crowns were removed. The tooth 26 (top left six) underwent trisection. A complete upper denture was anchored on top of three telescopic crowns. The photos below show the intraoral view before treatment and the condition after four years after completing the treatment.