Dental Tribune Pakistan Edition No.2, 2017

6(cid:9)DENTAL TRIBUNE(cid:9) Pakistan Edition(cid:9)March 2017 CLINICAL PRACTICE An indirect method for provisionalisation: the team approach in a complete mouth hybrid reconstruction By Dr. Robert A. Levine & Dr. Harry Randel A periodontist and ITI colleague whose office is two hours from our practices referred this patient to our team. Initially, she was seen by the prosthodontist, Dr Harry Randel, and subsequently referred to the periodontist, Dr Robert Levine, for a team approach to solve her failing dentition. The patient presented at our office as a 65-year-old non-smoking female (ASA 3: Illnesses under treatment: anxiety/ depression, osteoarthritis, fibromyalgia, hypothyroidism and history of myofacial pain dysfunction). There was a history of TMJ issues (i.e. clicking and pain with her right side TM joint) which presently is under control and pain-free.(cid:9) Her chief complaint was to improve her aesthetics and comfort with a desire for a permanent and quick solution to replace her failing dentition. She also desires a reduction of her maxillary anterior gummy smile in the final prosthesis. She arrived at our office for a third surgical consult for an immediate load maxillary and mandibular hybrid restoration using the Straumann Pro Arch treatment concept (tilting of the distal implants to avoid anatomic structures of the maxillary sinus, mandibular mental foramina). This treatment concept reduced the need for additional surgeries and number of implants needed to provide a fixed hybrid restoration with a first molar occlusion. A medium to high lip line was noted upon a wide smile with a bi-level plane of occlusion. Also noted was supraeruption of her maxillary and mandibular anterior teeth (FDI: #12, 11, 21, 22 and #41–43, US: #7–10 and #25–27) creating a deep bite of 6 mm. A Class I canine relationship was recorded with 6 mm overjet and 6 mm overbite. Due to her medication-related dry mouth issue, generalized recurrent caries were noted. Periodontal probing depths ranged generally from 4–7 mm in the maxillary jaw and from 4 to 6 mm in the mandibular jaw with moderate to severe marginal gingival bleeding upon probing in both jaws. Tooth #6 (FDI: #13) was noted to have a vertical fracture clinically. There was generalised heavy fremitus in her maxillary teeth and mobilities ranging from 2–3 degrees on the following teeth: #3, 7 thru 13, 20–26 and 29 (FDI: #16, 12, 11, 21–25, 31–35, 41–42 and 45). Her compliance profile was good with her previous dentists, however, she states that she has always had “issues with my gums.”(cid:9) The tentative treatment plan discussed at the initial visit with the patient and her husband included the following diagnosis: generalised moderate to advanced periodontitis; generalised recurrent caries related to medication-related dry mouth; posterior bite collapse with loss of occlusal vertical dimension (“mutilated dentition”). Prognosis: all remaining teeth are hopeless. Treatment plan: Obtain a CBCT of both arches to evaluate bone quality, bone quantity, and anatomical limitations. (cid:9) Articulate study models with fabrication of diagnostic full upper denture (FUD), full lower denture (FLD) and surgical guide templates. Team discussions to develop the final surgical and prosthetic treatment plan for hybrid restorations using the Straumann Bone Level Tapered Implant (BLT) with a first molar occlusion. Utilisation of an indirect technique will be used to fabricate the converted fixed laboratory metal-reinforced provisionals in one day.(cid:9) Coordination of the surgical visit (Dr Robert Levine) with the prosthodontist’s office (Dr Harry Randel), dental laboratory (NewTech Dental Laboratory, Lansdale, PA), and the dental implant company representative (Straumann USA, Andover, MA). The patient is aware of the possible need to wear one or both dentures during the healing phase if the insertion torque values are inadequate for immediate loading. This may be due to bone quality, bone quantity, or need for ex tensive bone grafting requiring a membrane technique for guided bone regeneration (GBR) and a two-stage approach. This is very important to review with all patients, especially when only four implants are planned in the maxilla, as the distal implant(s) may record poor insertion torque values due to bone quality and quantity. The ability to use longer, tapered (BLTs), and tilted implants—as in the present case—with adequate buccal bone available for the anticipated 4.1 mm implants help to reduce this possibility significantly.(cid:9) Delivery of the fixed provisionals in one day in the prosthodontist’s office followed.(cid:9) Post-operative visits every two to three weeks with the periodontist’s office for deplaquing, review of plaque control techniques and delivery of a water irrigation device at six weeks. An occlusal adjustment to be completed at each post-operative visit with the surgical and restorative offices, because the occlusion is very dynamic as the patient’s musculature continues to accept her newly restored occlusal vertical dimension (OVD). Time is also needed to stabilise her TMJ symptoms. Completion of final case at least three months post- surgery. Since the patient will be spending the winter in Florida, she will commence her final treatment when she returns in the spring.(cid:9) Periodontal maintenance every three months alternating between office will be observed. (cid:9)Based on CBCT analysis it was decided to place five implants in the upper jaw at the following sites: #4 (FDI: #15) (tilted), #7 (FDI: #12), between #8 & #9 (FDI: #11 & #21) (midline), #10 and #12 (FDI: #22 and #24) (tilted) after vertical bone reduction for prosthetic room. Four implants were anticipated to be placed in the lower jaw at sites #21 (FDI: #34) (tilted), #23 (FDI: #32), #26 (FDI: #42), & #28 (FDI: #44) (tilted). The anticipated position of each implant is ideally palatal in the maxilla to the original teeth and lingual to the original mandibular teeth. This is to allow for screw-access holes exiting away from the incisal edges anteriorly, and if possible, lingually to the central fossae in the posterior sextants. An additional benefit of palatal and lingual placement of each implant is that their final position will be at least 2–3 mm from the anticipated buccal plates, which is beneficial for long-term bone maintenance and implant survival. If the necessary 2 mm buccal bone to the final implant position is not available, then contour augmentation (bone grafting) is recommended to create that dimension. The goal is to prevent buccal wall resorption over time using slowly resorbing inorganic bovine bone and a resorbable collagen membrane. This membrane allows easy contouring and flexibility over the graft material when wet. It is also important to evaluate tissue thickness. It is ideal to have at least 2 mm of buccal flap thickness over each implant as thin tissues are associated with bone loss and recession over time. Either connective tissue grafts from the palatal flap or tuberosity can be harvested and sutured under the buccal flap. Alternatively, an allograft connective tissue or a thick collagen material can be used to thicken the buccal flaps when necessary. Surgical appointment The patient was pre-medicated with oral sedation (triazolam 0.25 mg), amoxicillin, a steroid dose pack and chlorhexidine gluconate (CHG) rinse, all starting one hour prior to surgery. The patient’s chin and nose were marked with indelible marker, and the OVD was measured using a sterile tongue depressor with similar markings while the patient’s mouth remained closed. The patient was then given full-mouth local anaesthesia.(cid:9) Starting with the maxillary arch, full-thickness flaps were raised and sutured to the buccal mucosa with 4-0 silk to provide improved surgical access and vision. The teeth were removed with the goal of buccal plate preservation using the PIEZOSURGERY (Mectron: Columbus, OH) for bone preservation (tips EX 1, EX 2, Micro saw: OT7S-3). The sockets were degranulated with Continued on page 08 PIEZOSURGERY (tip: OT4) and irrigated

Dental Tribune Pakistan Edition No.2, 2017

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