3 year follow up on : Compromised Implant Case: Design Options to Avoid Failure?

I believe it is always good to show follow up on cases to help both myself and others learn. Here is follow up on a case posted 3 years ago entitled Compromised Implant Case: Design Options to Avoid Failure. A quick synopsis is that the patient had terminal dentition, placed upper and lower implants with immediate extraction, bone reduction and delivered screw-retained temps. All upper implants failed. Explanted uppers, grafted, let it heal, replaced implants, but could only get on on R side (#6 area) and 3 on L side (#9, 11, 13 areas). I posted to show what happened and to see what others would suggest for upper design. Well, after many thoughtful comments, I decided to fabricate a lower fixed, CoCr based hybrid screw-retained prosthesis with acrylic and denture teeth. On the upper, I had an Atlantis bar with Locators fabricated and a removable, CoCr based acrylic horseshoe design with denture teeth. Here are the radiographs and photos I took yesterday. The following is some more history and a few comments on what I observed yesterday. I initially used the same lab that fabricated the surgical guide and initial temporary prostheses to fabricate the finals. Lab did a great job with the bar, however, I spun my wheels with them on fit, occlusion and esthetics. We went back and forth, delivering two sub-par prostheses in 2019. I lucked into finding a local, small lab who does these by having another patient come in and tell me who he had do his lower all on four. His dentist retired and he was referred to me...thank goodness! I had the new, local lab guy re-do the prostheses, in four appointments, and it was perfect. Final impression, framework and wax try-in #1, wax try-in #2 and delivery. I also had him fabricate an acrylic night guard that patient would attach to the Maxillary bar and help protect the lower acrylic/denture teeth from the bar and locator attachments. BTW, I wrote a dissertation to the original lab, informed them they did a great job with the surgical guides and with the bar fabrication, but asked for my money back on the final prostheses. They sent a check within a week. Just goes to show what keeping good records, photos and radiographs can do for you. As you can see from the radiographs, I am very happy with the integration and bone levels. Pt. was/is a parafunctional bruxer, so it makes sense that his #9 denture tooth has broken off. He went to another local lab to have them fix the tooth in February, but it came out. That is how he finally came in for a cleaning/recall appointment and I fixed the tooth. You can see from the wear on the lower that he does not wear his night guard. He is returning next week for an evaluation of the guard. He now understands how important it is to wear it since he will sooner rather than later have to have all of the denture teeth replaced! So far, so good with this case. Stress seems to be distributed well on the upper denture, upper bar and implants which was my biggest concern. The bar is key, if I went with 4 tissue level Locators, I do not think he would have as much retention as he does and I think it would have had more of a chance to overload the lone implant on the UR. So, these are my observations and I am very happy (so is he) with the outcome so far. Now, let's get your thoughts and comments. What could have been done to improve what is there now, what do you see into the future of this case? Thanks, this has been fun and I hope a great learning experience for everyone. - Eric
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