WHAT!!! How is that Even Possible?

It was in the month of June, I got a WhatsApp message from my friend, who is dentist & practices close to Hubli. A case of severe fluorosis, many teeth worn out, badly discolored can we help him, he is young. A few days later the patient came to our clinic, we did his clinical examination which included x rays, Intra oral scan, photographs and CBCT. While taking his photographs, it was difficult to make him smile. We could sense the pain he had with his smile; he was very conscious of it.

It was a challenge to rehabilitate him. How is that even possible? was the 1st thought. He is just 28, lost most of his teeth. His primary concern was esthetics & secondly eating.

Intra Oral View.

This was the available inter arch space for us.

Thin mucosa

Multiple Root Pieces

OPG X ray

Multiple Infected root pieces

When we have a look at such a scenario, we get a big question in our mind, HOW???

Is it possible to help him?

Listing down the challenges & thinking them over, looking for the best solution from our experience, helps a lot.

After examining all the data, we had the following challenges

1. Reduced inter-arch space -

2. Multiple decayed teeth - with periapical infection in all teeth. All teeth would require Root Canal, Post & Core followed by Crown lengthening & Crowns. If we save them, how long will they last? or should we extract them & for implant supported prosthesis

3. Bilateral Oral Sub Mucous Fibrosis - This was a major concern as it would restrict the movements, angle of the instrumentation.

4. Budget - Always an issue.

We took an Endo opinion which came out to be questionable as we would have difficulty in instrumentation in the molars.

Anyways, we drafted 2 plans.

Plan 1 - Save the teeth - Multiple RCT's, Post n Cores, Crown lengthening & Crowns with a few implants.

Plan 2 - Remove all teeth, go for implant supported prosthesis in the upper & lower jaw.

All the points of the plan were shared with the patient, the pros & cons of each. After careful consideration, the patient & us decided to go for FMR on Implants as the best option.

For Implant based Rehab, we had to

1. Create space for the prosthesis by crestotomy. We were limited by the amount of vertical bone available.

2. Bilateral OSMF - lots of frustrating time trying to get the instrument at the right place. Lots of patience from the doctor & patient

Here was the Plan

1. Extract + Curettage

2. Crestotomy with Upper & lower

3. One-piece multiunit implants

4. Immediate Provisionalisation

5. Screw retained PFM prosthesis with immediate loading

6. T Scan for Occlusion Balance

7. LASER therapy for OSMF

The Surgery went well, we extracted teeth & completed crestotomy on day 1 & did the implants on day 2. Doing the extraction & implants in one day would be too harsh on both of us. We got excellent primary stability >60Ncm with all the implants. In the pterygoid region we went for conventional multi-unit abutment 50deg. We were good to go for scanning of the scan bodies.

The Prosthesis was designed, which was printed in our in-house 3-D Printer. In 24 hours, the patient had teeth & was able to eat & go to the office. There are multiple benefits of providing a 3D printed provisional. One, the patient's life is restored. He can go to his office, he starts eating. The prosthesis provides protection to the underlying healing tissues. We can verify the esthetics, make the necessary changes. This saves time, improves patient comfort & the result of the treatment.

3D Printed Provisionals in place. They help us verify the fit, shape & size of the teeth & occlusion

Over the course of time, we completed the metal trial, bisque trial & final fixing of the prosthesis. T Scan based digital bite balancing was done at Bisque trial stage & also at Final fixing.

Porcelain Fused to Metal crowns in place.

Overall, we were happy with the result we achieved, considering the extreme challenges that we had to face & overcome.

The patient is on a follow up routine now & is doing fine enjoying his meals. He has been referred to LASER centre for treatment of OSMF.

It is cases like this that push the boundaries of implantology. Lots of skill, experience, and planning go into bringing out such transformation. Making the impossible, possible... Thats the fun... Grateful to Lord Krishna for having given me the skills to bring about such a transformation in people

When we see the result, the way he can smile & eat, makes it all worth the effort.