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Case 2.

Upper and Lower full arch implant reconstruction of advanced chronic periodontal case using an immediate placement protocol.
Pre-operative OPG
Taken to assess the dentition, gauge the quantity of bone and check anatomical structures.
Note the generalised degradation of the periodontal bone levels.
Note the prominent mental foramen and ID canals.
Pre-operative OPG
CT scan of the mandible to determine depth and 3D anatomy of mental foramen which in this instance was 12.5mm. CT scan of the mandible
CT scan of the mandible to demonstrate the bone height and width in the anterior region. In this view the mandibular bone is of sufficient height and width for an implant without the obvious need for bone grafting. CT scan of the mandible
Immediately post surgery OPG taken to confirm positioning of implants. The OPG demonstrates the satisfactory placement of 6 implants in the maxilla and 5 implants in the mandible. There appears to be sufficient space from anatomical structures; maxillary sinuses, ID canals and mental foramina. Not slight angulation of implant 35 to avoid mental canal canal. surgery OPG
Front view of articulated study models. Note the lower median spacing due to the loss of the lower centrals.
Pre-Treatment 1 Pre-Treatment 2 Pre-Treatment 3
Front view of articulated immediate dentures. Vertical dimension maintained, with premolarised balance occlusion.

The diagnostic restoration has no flanges to avoid damaging the labial plates.
Front view of articulated immediate dentures Front view of articulated immediate dentures 1 Front view of articulated immediate dentures 3
Lower and upper views of articulated immediate dentures.

Note the shortened premolarised occlusion. This was to allow the patient to adaptto a shorter dental arch and narrower occlusal table.
Lower and upper views of articulated immediate dentures Lower and upper views of articulated immediate dentures1  
These dentures will be inserted immediate together with the immediate implant placement, immediate loading is not intended.

The dentures will be used as a diagnostic to the definitive implant supported restoration. Note full complement of lower centrals
dentures dentures 1  
Lips at rest. Note the competent lip at rest. Also sunken appearance of lower third of face and deep labial fold at the oral commissure. Lips at rest
Full smile. Note the low lip line and protruded upper left central. Lips at Full smile
Generalised advanced periodontal destruction. Also the large space between the remaining lower central incisors. periodontal destruction
Note the tongue position - could suggest a tongue thrust which has exacerbated to protrusion of the periodontally compromised lower incisors. periodontal destruction 1
  periodontal destruction 2
UL1 and protrusion UL1 and protrusion 1
Note protrusion of the UL1 and protrusion and irregularity of the lower incisors.
Frontal view post surgery with dentures in- situ. Frontal view post surgery
Right retracted view. Right retracted view.
Left retracted view post surgery with dentures in-situ for 6 months after implant placement and extraction..

Note: the even contact in occlusion.
Left retracted view post surgery
Ridged acrylic verification jigs are made on the implant abutments positioned on the analogue model.

The verification jigs are then tried in the mouth to confirm the accuracy of the transfer impression used to produce the model before proceeding to framework fabrication.
Ridged acrylic verification Ridged acrylic verification 1
  Ridged acrylic verification 3 Ridged acrylic verification 4
  Ridged acrylic verification 5 Ridged acrylic verification 6
The fabricated frameworks are tried in the mouth to confirm fit.

The upper and lower six anterior teeth are applied to the frame work. This allows the position, size and shade of the teeth to be confirmed in the mouth for patient approval. Adjustment in incisal level and cant made and centre lines confirmed.
fabricated frameworks fabricated frameworks
  fabricated frameworks 3 fabricated frameworks 4
  fabricated frameworks 4 fabricated frameworks 5
Definitive restoration should be a match to the diagnostic as determined at the start of treatment.    
Definitive restoration Definitive restoration 2 Definitive restoration
The improved soft tissue support and corrected vertical dimension have resulted in a corresponding improvement in the oral commissure compared to the start picture below. Definitive restoration 4 Definitive restoration 6
Lip at rest Lip at smile Lip at full rest