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implants_international magazine of oral implantology No. 1, 2016

case report | 311 2016 implants implant between SF and the inferior alveolar nerve (IAN).2,3,5–7,9,10 Case This article discusses the unexpected findings that continuously emerged throughout the treat- ment process due to the absence of CBCT imaging in the initial phase of diagnosis, as well as the in- sufficiency of panoramic radiographic images in that clinical situation. The patient’s initial situation was characterised by a lose three-unit fixed partial denture, 45 im- plant supported, 46 pontic and 47 implant sup- ported. Initially, the patient opposed the use of a radiograph and, as a consequence, the need for implant ex­traction was misdiagnosed. Eventually, in order to complete the extraction, all three types of common radiography techniques—periapical, panoramic and CBCT5—were needed and ap- plied.5,7,10 The main complaint of the 65-year-old non-smoking male with no medical history or use of medication was “my bridge is moving and re- quires re-cementing”. During an emergency ap- pointment, the patient enquired about the costs for the re-cementing of a three-unit bridge. The patient presented a six-month-old periapical ­radiograph (Figs. 1a) while declining to take any further X-rays for a simple bridge re-cementing procedure. According to the patient, the implants were placed five years ago and without incision by a now-retired dentist who could no longer be con- tacted. After analysing the radiograph and making a clinical assessment, the provisional diagnosis showed that the bridge was moving due to an abutment screw loosening (Fig. 2). The resulting treatment plan called for the removal of the three- unit bridge and the re-tightening of the abutment screw to the manufacturers recommended pre- load as well as the re-cementing of the bridge (plan A). The patient approved the suggested procedures and signed the treatment plan. The bridge was found to be firmly attached to the anterior implant and loosely connected to the posterior one. The existing bridge had to be cut out and replaced by a new three-unit bridge (plan B). A small opening of the screw access hole was attempted on both implant restorations 45 and 47 (Fig. 3). Although the access hole did not lead to the abutment screw, the bridge mobility was increased. A periapical ­radiograph was obtained to evaluate the peri-­ implant status of the posterior implant (Fig. 1b). The radiolucency observed around the fixture indi- cated ­implant failure and the crown in the anterior implant had to be sacrificed in order to get to its abutment safely. At this stage (plan C), the proce- dures were set out as follows: removal of the ­posterior implant followed by a re-implant, a new temporary crown on tooth 45 and, after two months, fitting of a two-unit bridge instead of the previous three-unit bridge restoration. This deci- Fig. 1a Fig. 1b Fig. 2 Fig. 3 Fig. 4 Fig. 5 Fig. 1a: Periapical radiograph. Fig. 1b: Digital periapical radiograph. Fig. 2: Occlusal view of the bridge. Fig. 3: Occlusal view after attempting to get to the abutment. Fig. 4: Panoramic radiograph, diagnosis. Fig. 5: Occlusal view of PFM bridge. 3112016

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