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Dental Tribune Middle East & Africa Edition | September-October 2015 35implant tribune > Page 36 The tertiary structure provides the removable prosthesis with the stability required. All three structures together form a tension-free implant-supported prosthetic restoration. G A M E C H A N G E R TURN CLASS II INTO SIMPLE CLASS I PATIENTS © 2015 Ortho Organizers, Inc. All rights reserved. CARRIERE® MOTION™ CLASS II APPLIANCE Simplicity, ease of use and patient compliance add up to fast, more predictable results. With its sleek, aesthetic and non-invasive design, the Motion Appliance shortens treatment time by up to four months. Easier than Herbst® , simpler than Forsus® , and faster than elastics alone, the Motion Appliance can be a real game changer for your practice. Fixed Cuspid Pad with Hook Molar Ball & Socket Sleek and Non-Invasive Class II corrected in 3 months, 1 week Total treatment time 13 months with SLX New Carriere® SLX™ Bracket OrthoOrganizers.com Easy, fast and precise ByCristianPetri,CDT,Romania C reating an esthetically pleasing smile in an eden- tulous patient is no easy task. Effective collaboration, combined with suitable materi- als and procedures, empowers dental professionals to address this challenge effectively. Rehabilitation of the edentu- lous jaw can be achieved with various treatment modalities. Removable implant-supported overdentures can provide a comfortable, esthetic and func- tional option even in circum- stances where only a reduced number of implants can be used. This treatment option is frequently practised due to the fact that the number of patients wishing to find an alternative to complete dentures is rising. The patients‘ expectations regarding their prosthetic tooth replace- ments are similarly high as for fixed ceramic veneered resto- rations. With the emergence of new materials and their combi- nation with CAD/CAM technolo- gy, outstanding outcomes can be achieved for this indication. An adequate solution can be found for almost every patient and budget. Generally, overdentures offer several advantages over conventional removable pros- thodontics. These advantages include stability, functionality, comfort, confidence in the abil- ity to interact socially, straight- forward rehabilitation and easy maintenance for the patient, or, simply put: a significant im- provement in quality of life. Clinical case A 58-year-old patient presented at the practice with discomfort caused by her complete upper denture. At history taking, we found a prosthetic restoration retained on six implants in the lower jaw and a complete maxil- lary denture that was esthetical- ly and functionally inadequate (Fig. 1). An initial esthetic evaluation re- vealed that the shape and shade of the teeth were inappropri- ate. In addition, the midline was misaligned and the curva- ture of the maxillary anterior group was shaped incorrectly. The poor stability of the den- ture was caused by insufficient prosthetic support and by the method of manufacture. Taking into account the patient‘s re- quirements, financial possibili- ties and clinical condition of the maxillary prosthetic field, we decided in favour of an implant- supported prosthetic treatment modality. The plan was to insert four maxillary implants to retain an overdenture prosthesis using the double-crown method. This procedure is frequently prac- tised in such cases and has been improved with the emergence of new technologies and materials. Our protocol required primary telescope crowns milled from zirconia at an incline of 2° and secondary copings obtained by galvanoforming. This approach combines the advantages of zir- conia (primary telescopes) with the advantages of hydraulic re- tention (galvanic copings). Following a complication-free period of healing and osseointe- gration, the four implants were uncovered and a preliminary impression was taken. From the resulting model, a customized tray was created. Next, a func- tional impression that would transfer the exact position of the implants was required to proceed to the next stage of the treatment. The four impression posts were splinted together on the custom tray using compos- ite material (Figs 2 and 3). After creating the working models (Fig. 4), we determined the pa- tient‘s vertical dimension of oc- clusion (VDO), length of future teeth and gingival smile line by means of an occlusal plate (bite rim). In the upper jaw, the oc- clusal rim was shaped in such a way that two millimetres of the edge were visible when the upper lip was in rest position. The lower edge of the rim was aligned in parallel to the bipu- pillary plane and smoothly fol- lowed the curve of the lower lip when the patient smiled. On the maxillary rim, the midline, the smile line and the line of the ca- nines were outlined. A facebow was used for the transfer of the maxillary position in relation to the base of the skull. Once the relevant ratios had been obtained, the models were mounted on the articulator (Fig. 5). The difficulty of this case was that we had to make allow- ance for the existing mandibular restoration in the design of the maxillary rehabilitation. The implant axes of the mandibular prosthesis in particular posed some problems. Shade selection was dictated by the mandibular restoration and, consequently, our room for decision-making was reduced to deciding on the shape of the teeth. To this end, a photo of the patient as a young adult came in handy, as it was her wish that the shape and size of her teeth as they were when she was young should be main- tained in the prosthetic recon- struction. With the aim to attain as perfect a prosthesis as possible and to make the most of the available space, we created a wax setup using prefabricated denture teeth (SR Phonares® II). Primary structure A try-in of the setup was per- formed to check the phonetics, esthetics and occlusion (Fig. 6) and then a silicone key was cre- ated over the setup. The silicone key acted as a guide in the sub- sequent working steps. To man- ufacture the primary structure, the four titanium abutments were customized (Fig. 7), the re- sulting abutments were scanned together with the model and setup (double scan) and these data sets were imported into the design software. The CAD pro- gram proceeded to suggest the shape, height and angulation of the telescope crowns, which we adjusted and optimized as required (Fig. 8). The primary telescopes were milled from zirconia and sintered to their final density at 1500°C. After checking the accuracy of fit, the zirconia crowns were perma- nently bonded to the titanium abutments (Multilink® Hybrid Implant-prosthetic restoration of an edentulous maxilla