Please activate JavaScript!
Please install Adobe Flash Player, click here for download
ePaper created 2018-02-22, 14:08:19 | version 1.38.0
Figs. 1a–c. Retracted frontal, occlusal maxillary and occlusal mandibular views exhibit the non-restorable preoperative state of the patient’sdentition. Figs. 4b. Occlusal views of patient’s max- illary and mandibular ridges exhibit healthy tissueat theextractionsites. Figs. 5a & b. Surgical guides were 3-D printed to help ensure placement of the implants inaccordancewith thedigital treatment plan. Dental Tribune Middle East & Africa Edition | 5/2016 30 CAD/CAM Complete reconstruction for a patient with chronic tooth decay The damage undone ByDrAraNazarian,USA When oral health is neglected for ex- tensiveperiodsoftime,dentalcondi- tions like tooth decay and periodon- tal disease can advance to a point that, prior to the advent of implant therapy, was considered hopeless. If a patient presented with exten- sive caries and a non-restorable set of dentition, practitioners had no choice but to extract the teeth and provide the patient with a complete denture. Although beneficial to pa- tientsasafundamentalreplacement of their teeth, many patients have found the fit, comfort and retention of such appliances to be problem- atic.1 Without any anchorage to hold it in place, the traditional denture has a tendency to move around in the patient’s mouth, compromis- ing speech and chewing capabili- ties. This problem is exacerbated by the recession of the edentulous arch that occurs following tooth loss or extraction.Afterdecadesofadvance- ments in implant design, restorative materials, and digital dentistry, we can today provide patients with a higher level of care. Root-form den- tal implants can be placed predict- ably to hold a full-arch prosthesis in place, providing greatly improved comfort, function, and quality of life compared to traditional com- plete dentures.2,3 Further, osseoin- tegrated implants serve to mitigate bone resorption.4 This means that in addition to providing the aesthet- ics of natural dentition, implant- supported restorations also help to preserve the edentulous ridge and the essential support it provides for themouthandface.Thepositiveim- pact this can have on personal confi- dence, emotional health, and social interactionsissubstantial.5 Thus, patients who present with the most acute dental conditions can now be brought back from the brink and become fully restored via implant therapy. If the patient’s teeth have deteriorated to the point where they can no longer be saved, they can be extracted, implants are placed, and a full-arch restoration is delivered that closely emulates the form and function of natural den- tition. This alternative should be presented to all patients for whom implant therapy is indicated, as indi- viduals who at first may not appear to have the means for high-quality treatment may in fact have the wherewithal after being apprised of their options. Additionally, all pa- tients should be made fully aware of the long-term costs and benefits of traditional complete dentures vs. implant-supported restorations before making a decision with such life-changing potential. The pres- entation that follows documents a case in which a patient with severely decayed dentition undergoes a com- pleteoralreconstruction. A treatment plan is developed that harnesses the classic principles of implant placement, the versatility of modern restorative materials, and the precision of digital diagnostics andCAD/CAMfabricationtoachieve a predictable, aesthetic restoration for a case that would seem hopeless to many. The case illustrates how implant therapy can afford patients even in the most extreme of dental circumstances an excellent long- term prognosis, restoring not just the teeth, but also the bone, soft tis- sue,self-esteem,andqualityoflife. CaseReport A36-year-oldmalepatientpresented for treatment with advanced, exten- sive caries and localized periodontal disease (Figs. 1a–c). In addition to not having seen a dentist in more than 20 years, the patient was recover- ing from an addiction to metham- phetamine, which had caused ex- cessive clenching and grinding that had substantially worn down the patient’s teeth. The many years of dental neglect combined with these parafunctional habits to render the patient’s severely decayed denti- tion untreatable (Fig. 2). Further, the deterioration of the patient’s teeth wasaccompaniedbysignificantsoft- tissuerecessionandboneresorption. Although the patient had been quite apprehensive about seeking treat- ment,painanddiscomforteventual- ly compelled him to take action. The patienthadsoughttreatmentfroma practice where he could receive all of the necessary treatment from a sin- gle provider in the fewest appoint- ments possible. After locating my practice, the patient found the cour- age to present for evaluation. It was apparentfromtheinitialvisitthathe wasashamedofhiscondition. Fig. 6. The surgical guides were seated in the patient’s mouth and secured using thefixationpinsandpositioningindex. Fig. 7. The surgical guides controlled the positioning of the osteotomies during drilling. Fig. 9. The impression copings were tight- enedintoplaceusing theball-topscrews. Figs. 8a & b. Occlusal views of maxillary and mandibular implants illustrate excellent healingof thesoft tissuefourmonthsaftersurgery. The goal was to offer him the best treatment available in order to re- store the patient’s smile, form and function. Without presuming the appropriate standard of care for the patient based on his condition, it was explained to the patient that his natural teeth could not be saved andafullrangeoftreatmentalterna- tives was presented, from complete dentures to fixed full-arch implant restorations. Before-and-after pho- tos of similar cases were shown to the patient to assist his evaluation of the restorative options. The pa- tient chose full-mouth reconstruc- tion consisting of fixed prostheses delivered over dental implants. A treatment plan was developed that included extraction of the patient’s non-restorable dentition, the place- ment of eight implants in each arch, delivery of Inclusive® Titanium Cus- tom Abutments and BioTemps® res- torations (Glidewell Europe GmbH; Frankfurt/Main, Germany), and final restoration with fixed PFM prosthe- ses. The latest tools in digital dentist- rywouldbeutilisedtomaximizethe precisionofbothimplantplacement andprostheticfabrication. Because of the patient’s relatively youthful age and his continued bruxing habit, eight implants were proposed for each arch in order to maximise the distribution of oc- clusal load, the preservation of his ridges, and the long-term prognosis of the restoration. The resorbed state of the patient’s maxillary and man- dibularridgesnecessitatedagrafting procedure to create the foundation needed for implant placement. Cus- tom abutments would be used to position the prostheses for optimal aesthetics. Although BruxZir® Solid Zirconia Full-Arch Implant Prosthe- ses (Glidewell Europe GmbH; Frank- furt/Main, Germany) would have been the ideal restorations given the need for long-term durability in this case, the product was not yet avail- able at the time of treatment. Thus, PFMprostheseswerechoseninorder to avoid acrylic and its susceptibility to staining, wear and fracture. The proposed PFM restorations included layered pink porcelain to recreate the patient’s natural gingival con- tours. All aspects of treatment were explained to and accepted by the pa- tient.Thefirstphaseoftreatmentbe- gan by atraumatically extracting the patient’sentiredentitionusingPhys- ics Forceps (Golden Dental Solutions Inc.; Detroit, USA), which allowed for removal of the teeth without caus- ing any damage to the surrounding bone. The extraction sockets were filled with grafting material in order to preserve the sockets and rebuild themaxillaryandmandibularridges for ideal implant placement. The pa- tient was provided with immediate dentures, which were prefabricated based on impressions that were tak- enatapreviousappointment(Fig.3). After approximately five months of healing, the patient was called in so cone-beam computed tomography (CBCT)scanningcouldbeperformed. The soft tissue of the patient’s now- edentulous arches exhibited excel- lent health (Figs. 4a & b). CBCT scan- ning confirmed that the grafting procedure was successful in increas- ing the bone volume available to ac- commodate the planned implants. The CBCT scanning data was used to devise a virtual treatment plan that would place the eight implants for each edentulous ridge in the maxi- mum amount of bone while adher- ing to the key implant positions as taught by Dr Carl Misch.6 Surgical Fig. 2. Panoramic radiograph further il- lustrates the extensive tooth decay the patient had suffered, which had caused a majorinfectionasevidencedbytheradio- lucent lesions visible at the tips of several roots. Also note the periodontal lesions visiblein thelowerarch. Fig. 3. Following extraction of the pa- tient’s dentition, immediate dentures weredeliveredtoprovidethepatientwith aminimumleveloffunctionandaesthet- icsduring thehealingphase. Figs. 4a. Occlusal views of patient’s max- illary and mandibular ridges exhibit healthy tissueat theextractionsites. ÿPage 32