Full Mouth Rehabilitation with Dental Implants and Fixed Dental Prostheses

Advances in dental implant research, design and their clinical application have greatly changed dental care. Improved protocols in implant therapy over the last several decades have made implant supported restorations biologically and mechanically predictable.1-5 However, there is still a role for conventional tooth supported fixed dental prostheses.6 Full arch implant-supported restorations are increasingly popular, but many patients are not psychologically ready for the extractions and alveolectomy that is often required. The following case presentation demonstrates the combined use of dental implants and tooth supported fixed dental prostheses to restore the patient’s esthetics and function.

Fig1
FIGURE 1. Smile photo of the patient at initial presentation.

Fig2
FIGURE 2. Frontal view at maximum intercuspation at initial presentation.

Fig3
FIGURE 3. Maxillary occlusal view at initial presentation.

Fig4
FIGURE 4. Mandibular occlusal view at initial presentation.

Fig5
FIGURE 5. Panoramic radiograph at initial presentation.

Fig6
FIGURE 6. Diagnostic wax-up of posterior teeth after stone duplication of the anterior wax-up.

Fig7
FIGURE 7. Diagnostic wax-up of the planned occlusal plane.

Fig8
FIGURE 8. Frontal view of acrylic provisionals.

Fig9
FIGURE 9. Frontal view of provisionals in protrusion.

Fig10
FIGURE 10. Frontal view of provisionals in right laterotrusion.

The patient presented with the chief complaint of poor esthetics and difficulty in mastication. The patient reported having hypertension and hyperlipidemia, which was treated and controlled by the patient’s physician. The patient smoked one pack a day but quit nine years ago. Many years of infrequent dental visits had resulted in a loss of many posterior teeth. The loss of posterior support, compounded with caries, periodontal disease, attrition and fracture, led to the loss of vertical dimension, extrusions, malpositions and a compromised plane of occlusion.

 

Fig11
FIGURE 11. Frontal view of provisionals in left laterotrusion.

Fig12
FIGURE 12. Right view of provisionals at maximum intercuspation.
Fig13
FIGURE 13. Left view of provisionals at maximum intercuspation

Fig14
FIGURE 14. Smile photo of patient with provisional restorations.

Fig15
FIGURE 15. Maxillary occlusal view at time of final impression.

Fig16
FIGURE 16. Mandibular occlusal view at time of final impression.

Fig17
FIGURE 17. Right view at time of final impression.

Fig18
FIGURE 18. Left view at time of final impression.

Fig19
FIGURE 19. Fabrication of custom impression copings using pattern resin to duplicate the emergence profile of the provisional implant restorations.

Fig20
FIGURE 20. Custom impression copings accurately capture the soft tissue profile and transfer that information to the laboratory technician. It also splints open tray impression copings together during the impression.

Alginate impressions were taking to fabricate diagnostics casts after a comprehensive extraoral and intraoral exam. After determination of the etiology and diagnosis of the patient’s condition, CR records were taken at an increased vertical dimension of 1 mm. Casts were mounted and a diagnostic wax up was completed for the anterior teeth. A posterior denture tooth set up was completed on the same casts. After patient approval, anterior teeth were prepared and provisional restorations were fabricated. A jig in the posterior region helped transfer the planned vertical dimension on the articulator to the patient. Posterior teeth were extracted and immediate interim mandibular and maxillary partial dentures were delivered after anterior provisionals were completed. The provisional restorations provided function and esthetics while the increased vertical dimension, plane of occlusion, and functional movements were evaluated.

Fig22
FIGURE 21. Maxillary final impression. Custom impression copings were sectioned and re-luted intraorally to compensate for material shrinkage.

Fig22
FIGURE 22. Mandibular final impression capturing teeth preparations, implants, and soft tissue profile.

Fig23
FIGURE 23. Maxillary metal frameworks.

Fig24
FIGURE 24. Mandibular metal frameworks to be tried in.

Fig25
FIGURE 25. Right view of frameworks on a semi-adjustable articulator.

Fig26
FIGURE 26. Left view of frameworks on a semi-adjustable articulator. Occlusal clearance for porcelain is evaluated.

Fig27
FIGURE 27. Maxillary final restorations.

Fig28
FIGURE 28. Mandibular final restorations.

Fig29
FIGURE 29. Frontal view of final restorations at delivery in maximum intercuspation.

Fig30
FIGURE 30. Frontal view of final restorations in protrusion.

Fig31

After three months of healing, a secondary wax up of the posterior teeth was completed. Radiographic and surgical guides were fabricated. A CBCT evaluation was done. AstraTech Osseospeed implants were placed at sites #16,15,14 and #24,25,26 with a concurrent right lateral sinus augmentation. Implants were also placed at sites #36, 34, 44, 46. After three months of healing, all implants were uncovered and direct screw-retained implant provisionals were fabricated. All provisional restorations were adjusted to train the soft tissue, evaluate esthetics, phonetics, centric and eccentric tooth contacts. The goal was to transfer this information accurately to the laboratory so the final outcome was predictable. Investing more time in the provisional restorations reduced the chance of adjustments or remaking the definitive restorations.

Fig31
FIGURE 31. Frontal view of final restorations in right laterotrusion. Canine guidance was developed.

Fig32
FIGURE 32. Frontal view of final restorations in left laterotrusion. Canine guidance was developed.

Fig33
FIGURE 33. Maxillary occlusal view of final restorations.

Fig34
FIGURE 34. Mandibular occlusal view of final restorations.

Fig35
FIGURE 35. Right view of final restorations.

Fig36
FIGURE 36. Left view of final restorations.

Fig37
FIGURE 37. Smile photo of patient with final restorations.

Fig38
FIGURE 38. Panoramic radiograph at final delivery.

After the patient was satisfied with the provisional restorations, the task was to transfer the information to the laboratory so definitive restorations have similar esthetics and function. To capture the soft tissue architecture, customized impression copings were fabricated using pattern resin. This prevented any soft tissue collapse immediately after removal of the provisional restoration and it was less likely the definitive restorations will be under or over-contoured. After material shrinkage, the resin was sectioned and the impression copings were reluted intraorally. A final open tray impression was taken using heavy and light-bodied polyvinylsiloxane capturing both implants and tooth preparations. Alginate impressions were taken of the provisional restorations and these casts were cross-mounted to the master casts using the screw-retained implant provisionals. This allowed the technician to fabricate definitive restorations that followed the plane of occlusion determined by the provisionals. In addition to a facebow transfer, the cross-mounted casts of the provisionals provided the technician with information regarding the occlusal cant, length, angulation, size and shape of the restorations determined by the practitioner and the patient. Metal frameworks were tried in to determine the fit, marginal seal and proper support for porcelain. Definitive restorations were tried in and occlusion, contacts, fit and retention were checked. Ceramometal crowns on #13, #12 and fixed dental prostheses from #11-x-22-23 and #33-32-x-42-43 were cemented with a resin-modified glass ionomer cement. Posterior implant screw-retained splinted restorations in the maxilla from #16-15, #25-26 and single screw-retained crowns at #14, #24 were torqued in. Mandibular implant restorations from #34-x-36 and #44-x-46 were also delivered. Screw access holes were filled with teflon tape and composite. A nightguard was fabricated for the patient to minimize risk of porcelain chipping and fracture. Frequent recalls and maintenance for this patient was crucial to prevent the recurrence of caries, periodontal disease and prosthetic complications.OH


Dr. Siu is a board certified Prosthodontist practicing at Dr. Mark Lin Prosthodontic Center, Markham Family Dentistry, and Foresthill Prosthodontists.

Oral Health welcomes this original article.

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3. Scheller H, Urgell JP, Kultje C, Klineberg I, Goldberg PV, Stevenson-Moore P, et al. A 5-year multicenter study on implant-supported single crown restorations. Int J Oral Maxillofac Implants. 1998;13(2):212-8.

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5. Jung RE, Pjetursson BE, Glauser R, Zembic A, Zwahlen M, Lang NP. A systematic review of the 5-year survival and complication rates of implant-supported single crowns. Clin Oral Implants Res. 2008;19(2):119-30.

6. Torabinejad M, Anderson P, Bader J, Brown LJ, Chen LH, Goodacre CJ, et al. Outcomes of root canal treatment and restoration, implant-supported single crowns, fixed partial dentures, and extraction without replacement: a systematic review. J Prosthet Dent. 2007;98(4):285-311.