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Dental Tribune Middle East & Africa Edition | 4/2016 10 mCME Fixed and Removable Implant Restorations: A Solution for Every Arch mCMEarticlesinDentalTribunehavebeenapprovedby: HAADashavingeducationalcontentfor2CMECreditHours DHAawardedthisprogramfor2CPDCreditPoints ÿPage11 CAPP designates this activity for 2 CE Credits ByDr.PareshB.Patel,USA When a patient presents with an edentulous arch or terminal denti- tion, implant treatment can be pro- vided that improves not only form and function, but also quality of life. For patients desiring better chewing capability, stability, esthetics and comfort than a traditional denture can offer, both removable and fixed implant restorations are superior alternatives.1 While the appropriate implant solution can vary depend- ing on the patient’s oral health, anat- omy, quality and quantity of bone, and financial resources, full-arch prosthetics have progressed to the point where virtually every patient canberestored. Although fixed, implant-supported restorations offer the highest levels of stability, function and patient sat- isfaction, removable overdentures are a dramatic improvement over conventional complete dentures as well.2 Both treatment options ef- fectively mitigate the bone resorp- tion that occurs following the loss of teeth, helping to preserve the oral and facial structures and, by exten- sion, the self-confidence of the fully edentulous patient. Determining which solution is appropriate re- quires a careful evaluation of the individual patient’s circumstances and desires. Even when an implant overdenture is delivered, the pros- thesiscaneventuallybeconvertedto afixedrestoration. As evidenced by the case that fol- lows, in which one arch is restored with an implant overdenture and the other with a BruxZir® Full-Arch Implant Prosthesis, practitioners to- day have a great deal of clinical flexi- bility. Whatever prosthetic approach is adopted, immediate, life-changing reliefcanbeprovidedtopatientssuf- fering from terminal dentition or an uncomfortable, poorly functioning traditional denture. Further, the dra- matic overhaul of this patient’s oral health demonstrates the life-chang- ing capabilities of implant therapy, which helped him overcome severe functional and esthetic challenges that were impacting practically eve- ryfacetofhislifepriortotreatment. CasePresentation A 47-year-old male presented with terminal dentition in both arches resulting from periodontal disease and severe caries (Figs. 1a–1c). The patient had already lost many of his teeth, and the dentition that re- mained had been rendered unstable by his periodontal condition (Fig. 2). He had saved up enough money for a fixed implant restoration for his upper arch, for which he desired the most functional, lifelike prosthesis possible. While he couldn’t afford such a restoration for both arches, he wanted a retentive appliance for hismandible,withtheoptionoflater upgradingtoafixedprosthesis. The patient accepted a treatment plan in which his maxilla would be restored with a BruxZir Full-Arch ImplantProsthesisandhismandible with an Inclusive® Locator Implant Overdenture. Fabricating his maxil- lary restoration from monolithic zir- coniawouldensuremaximumlong- term durability. This was important provided the relatively young age of the patient, who would not have to worry about his upper prosthesis succumbing to fractures, chips or stains. Hislowerappliancewouldbeheldin place by connecting to the implants via Locator® attachments (Zest An- chors; Escondido, Calif.), which are an economical means of improving prosthetic retention and stability. The overdenture caps that connect to the Locator attachments would be incorporated in the prosthesis chairside, though it should be noted thatmanyclinicianselecttohavethe laboratoryhandlethisstep. The surgical phase of treatment called for the extraction of the pa- tient’s remaining teeth followed by Figures1a–1c:Preoperativeconditionof thepatient.Note thehighlipline,severecervicaldecaypresent on thepatient’sremaining teeth, andlackofgingivalsupport. Figures4a–4c:TheInclusiveTaperedImplantswere threadedintoplace,achievingexcellent initialstability. Figure 2: Preoperative panoramic X-ray exhibits periodontal disease, cervical caries, terminal state of the patient’s dentition, and the com- promisedstateofthesurroundingperiodontium,whichhadrendered the teethmobile. Figure 3: Maxillary implants with parallel pins in place exhibit the axial placement of the anterior implants and the tilted angulation of the posterior implants. Figure 5: Multi-unit abutment with carrier in place illustrates correction of the implant’s angulation to establish a uniform prosthetic platform around the arch. Figures 8a, 8b: Note the dramatic change in the appearance of the patient, who left with chairside-converted dentures in placeon thesamedayassurgery,includingascrew-retained,fixedprovisionalforhisupperarch. Figure 6: Traditional dentures were fabricated in ad- vance of the surgical appointment so they could be immediately converted to serve as temporary appli- ancesduring thehealingphase. Figure 9: Postoperative panoramic radiograph illustrates All-on-4 con- figuration of maxillary implants and axial placement of the man- dibular implants, which would facilitate a passive fit of the lower overdenture. Note the temporary cylinders attaching the provisional maxillarydenture to theimplants. Figures 7a, 7b: Same-day conversion of the maxillary denture to an immediate fixed prosthesis was achieved by adding multi-unit temporary cylinders using cold-cure acrylic and trimming the appliance into a horseshoe shape.