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22 RESTORATIVE Dental Tribune Middle East & Africa Edition | 6/2017 Replacing a failing dentition with new technology By Dr. Ara Nazarian, USA Having the ability to take a pa- tient from start to finish in a fewer amount of appointments within your practice allows you to position yourself as a provider that can fulfill your patient's surgical and restora- tive needs. With the proper train- ing, a dental provider may provide extraction, grafting and implant placement within one appointment at one location. Not only does this allow you to reduce the amount of visits for the patient, but this type of service also helps maintain the cost to the patient since they are not see- ing multiple dental providers. Most importantly, this enables the dental provider full control of the surgical and prosthetic outcome. Depending on the patient's desires, the clinical conditions of the oral environment present and the skills of the pro- vider, a dentist may choose to ex- tract teeth, level bone, and graft with guided dental implant placement within his/her dental practice. A pa- tient presented to my practice for a consultation wanting to restore her smile (Fig. 1). She complained of gen- eralised discomfort in her entire den- tition; probably due to the rampant caries and infection that was already present (Figs. 2–5). Having already visited multiple providers for an evaluation, she was very frustrated with conflicting treatment options offered. Either the suggested treat- ment would require multiple surgi- cal and restorative visits that would extend for a very long time or dental treatment would require a team ap- proach where little coordination by dentist and specialist was commu- nicated to the patient. Since many of these options did not appeal to her, the patient decided to have me pro- vide comprehensive treatment that would include extractions, bone lev- eling, grafting, dental implant place- ment, immediate provisionalisation and prosthetic rehabilitation within my own practice. When presenting cases like this to my patients, I will always use the Dine Digital Solution camera (Lester A. Dine). Not only is this camera small, light and waterproof, it also is very effective and clear in taking Fig. 1: Preoperative full face view close-up photos as well as full face shots. Additionally, I will always offer my patients a third party payment option like the Lending Club (San Francisco, CA) for their treatment. Lending Club Patient Solutions pro- vides patients great funding flex- ibility with very low rates and high approvals. Most of all, the support from their staff has been very profes- sional. Planning A CBCT scan was taken to accu- rately treatment plan this case to make certain that no complications would arise from doing all the pro- cedures (extract, graft and implant placement) within one visit. Since her entire dentition had rampant caries present, her treatment would require extracting teeth #2–15 and #18–31, as well as the impacted third molars (teeth #1, 16, 17, 32) to avoid any further complications in the fu- ture. To further develop a treatment plan, diagnostic models were forwarded to the dental lab and mounted on the articulator for further analysis in order to meet the patient’s aesthetic and functional needs. Instructions for a virtual wax-up were prescribed for increasing the patient’s vertical dimension due to a collapse in her bite from the severe wear in her den- tition. As a result of the information gath- ered from merging the CBCT infor- mation with the STML files of the Fig. 6: Hiossen guided kit Fig. 7: Fixed implant provisional restoration pick-up. Fig. 8: Fixed implant provisional restorations. Fig. 9: Clear duplicates of provisionals used for relations Fig. 10: 3Shape view of the proposed treatment Fig. 11: Monolithic zirconia restorations. Fig. 2: Preoperative retracted view biting. Fig. 3: Preoperative retracted view Fig. 4: Preoperative maxillary occlusal view Fig. 5: Preoperative mandibular occlusal view virtual wax-up, it was determined that aesthetics and function could be enhanced by restoring the patient’s entire maxillary and mandibular arches with implant supported res- torations. All risks, benefits and alter- natives of various treatment options were reviewed with the patient in- cluding dentures, over dentures and fixed restorations. Her treatment plan of choice would consist of screw retained fixed zirconia restorations in the upper and lower arches sup- ported by six implants each. With the combination of their cork- screw thread, built-in platform switching and apical design, the ET III SA (Hiossen) implant system was utilised in this particular case. Ac- cording to the manufacturer, the enhanced SA (sand blasted and acid etched) surface of this implant has shown a substantial quickening of gene expression, cell differentiation and proliferation that are essential to osseointegration meaning faster bone healing and earlier loading times. Other dental implant systems in the market with high initial stabil- ity may include but are not limited to; Biomedical Engage (OCO), Nobel Active (Nobel Biocare), Seven (MIS), I5 (AB Dental USA), Conus 12 (Blue Sky Bio) and Any-Ridge (Megagen). Not only was the type and size of the implant selected because of CBCT planning, but also its relationship to the planned restoration and its prox- imity to vital structures determined before performing the surgery. Guided bone leveling, as well as im- mediate implant placement, would be accomplished at the surgical ap- pointment by using CT-based bone leveling and implant drilling guides. Additionally, prefabricated screw- retained fixed provisional restora- tions would be directly picked up with acrylic over dental implants in the maxilla and mandible in the key implant positions if adequate fixa- tion was acquired. When performing this many proce- dures in one visit, I will utilise IV se- dation to make the procedure more efficient and comfortable for the patient as well as for myself. Since the patient is sedated, a mouth prop, Logibloc (Common Sense Dental Products), is used to keep her mouth open. Logibloc’s unique design stabi- lises and comfortably supports the jaw while allowing unrestricted visu- al and physical access to the working area for the provider. Once the patient was completely se- dated and anaesthetised, the teeth were extracted in a systematic man- ner, working in sections at a time starting from the anterior maxillary teeth. Acting like a modified class I lever, the Physics Forceps (Golden Dental Solutions) were used to atrau- matically extract the teeth with the goal of trying not to disturb the un- derlying bone. The beak of the for- ceps was placed on the lingual cervi- cal portion of each tooth, where the soft bumper portion was placed on the buccal alveolar ridge at the ap- proximate location of the mucogin- gival junction. During the extraction process, the beak grasps the tooth and the bumper acts as the fulcrum. Extractions were accomplished with only slight wrist action in a buccal direction taking about 40 to 60 sec- onds each depending on the tooth morphology and density of bone. Once all the maxillary teeth were extracted, the alveolar crest was lev- eled 2–3 mm apically following the parameters set by the bone leveling guide with the AEU-7000 surgical motor/handpiece (Aseptico), so that the patient’s transition line from the ridge to the prosthesis would not be visible when the patient smiled. Once completed, the surgical drill- ing guide was inserted and the sites for the implants were initiated with the Hiossen-Osstem Guided kit (Fig. 6). In the upper arch, six 4.0 mm diameter ET III SA dental implants were placed in the areas of teeth #4, 6, 8, 9, 11 and 13 to support an All on Six restoration. The most distal im- plants were angled in order to avoid the maxillary sinus cavities and any augmentation in that area. In the lower arch, several different ÿPage 23