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Managing complex anatomy and correcting arch asymmetry

by: Dr. Ian Lane

Dr. Ian Lane of the Queensway Dental Clinic in the UK takes you step-by-step through the treatment of a challenging case, including a mandible treated according to the all-on-4® treatment concept.

NobelClinician screen shots showing planning images from this case. The long anterior loop of the mental foramen was identified and accommodated in the planning.

Patient profile

  • Female
  • 64 years of age
  • Controlled hypertension, no other significant medical history
  • Wearing upper and lower partial CoCrMo dentures for many years, with individual teeth added when crowns or bridges failed
  • Asymmetric arch due to progressive tooth loss

As the result of the patient’s progressive tooth loss, I approached her case with the All-on-4® treatment concept in mind. She presented a severely atrophic maxilla and mandible, with a lower immediate prosthesis on a shortened dental arch. 

Seamless treatment planning process

Both for 3D diagnostics and treatment planning, we used NobelClinician Software. The case, which presented with some significant arch asymmetry, required a staged approach to ensure that the complexity of the planned treatment could be managed successfully.

My colleagues on the Queensway Dental Team (Consultant Oral and Maxillofacial surgeon, Mr. Rob Banks, Queensway Laboratory Managing Partner, Mr. Richard Elliot, and Prosthodontic Manager Mr. John Blenkey) and I carried out the prosthetic planning, the All-on-4® treatment concept surgery, immediate provisionalization and the laboratory work.

Demonstrating the importance of careful planning, the successful outcome of this case was accomplished through the use of NobelClinician, a 3D prosthetic-driven treatment planning software. The full 3D case planning approach was streamlined using the online collaboration tool, NobelConnect. It involved the surgeons, prosthodontist and prosthetic technicians, who used NobelProcera to make this graftless solution—which could be delivered to the patient in a primary care environment—possible. 

Designing a smile

Dr. Banks carried out the All-on-4® treatment concept surgery in the lower arch with a fixed temporary acrylic prosthesis and provided the patient with Immediate Function on the day of the surgery at the clinic in Billingham. The upper arch treatment was then carried out over a period of six months to allow implant placement and healing in a severely atrophic maxillary ridge. 

During this six-month period, we took a staged implant placement approach. Thanks to the 3D diagnostic features, the placement of the implants into the available bone in this manner avoided sinus grafting or extensive block grafting. Both pterygoid and anterior implant placement took place prior to delivery of the immediate temporary prosthesis. This cautious approach was adopted due to poor bone quality. 

The final prostheses were carefully designed after a phase of temporization to correct the arch asymmetry. This was made possible by using some of the techniques we had learned for managing complex occlusal schemes and facial symmetry from Dr. John Kois. 

Together with my partners, Dr. Paul Averley, Dr. Uzma Olbrich and Dr. Will Carter, and Queensway Dental Laboratory Managing Partner Mr. Richard Elliott, I completed a three-year training program delivered by Dr. Kois at his treatment and training center in Seattle, Washington, USA. This additional training has improved our ability to assess risk in complex cases and better design new smiles in circumstances such as these.

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