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Lab Tribune Asia Pacific No.1, 2017

Lab Tribune Asia Pacific Edition | 12/2017 TRENDS & APPLICATIONS 21 6 8a 7a 7b 8b 9 10a 10b 11a 11b 11c 12a 12b 13a Fig. 6: Conventional dentures were fabricated in advance of the surgical appointment so that they could be immediately converted to serve as temporary appliances during the healing phase.—Figs. 7a & b: Same-day conversion of the maxillary denture to an immediate ixed prosthesis was achieved by adding multi-unit temporary cylinders using self-curing acrylic and trimming the appliance into a horse- shoe shape.—Figs. 8a & b: Note the dramatic change in the appearance of the patient, who left with chairside-converted dentures in place on the same day as surgery, including a screw-retained ixed provisional for his upper arch.—Fig. 9: Post-op panoramic radiograph illustrates all-on-4 coniguration of maxillary implants and axial placement of the mandibular implants, which would facilitate a passive it of the mandibular overdenture.—Figs. 10a & b: The patient returned 14 weeks after implant surgery, and healing of the peri-implant tissue had progressed nicely.—Figs. 11a–c: Transfer cop- ings were attached to the maxillary multi-unit abutments, and an open-tray impression was made to serve as the basis for the working cast the laboratory would use to begin designing the restoration. Note that a closed-tray impression was taken for the mandibular implant overdenture.—Figs. 12a & b: For the recording of jaw relations, a mandibular wax rim was designed to seat over the Locator attachments, while a screw-down wax rim was created for the maxilla.—Figs. 13a & b: The maxillary wax rim was screwed into place through the temporary cylinders, while the mandibular wax rim was seated over the Locator impression caps. Case presentation A 47-year-old male presented with terminal dentition in both arches resulting from periodontal disease and severe caries (Figs. 1 a–c). The patient had already lost many of his teeth, and the dentition that remained had been rendered un- stable by his periodontal condition (Fig. 2). He had saved up enough money for a ixed implant restora- tion for his upper arch, for which he desired the most functional, lifelike prosthesis possible. While he could not afford such a restora- tion for both arches, he wanted a retentive appliance for his mandi- ble, with the option of later upgrad- ing to a ixed prosthesis. from monolithic zirconia would ensure maximum long-term du- rability. This was important con- sidering the relatively young age of the patient, who would not have to worry about his maxillary pros- thesis succumbing to fractures, chips or stains. His mandibular appliance would be held in place by connecting to the implants via Locator attachments (Zest Dental Solutions), which are an economi- cal means of improving prosthetic retention and stability. The over- denture caps that connect to the Locator attachments would be in- corporated in the prosthesis chair- side—though it should be noted that many clinicians elect to have the laboratory handle this step. The patient accepted a treat- ment plan in which his maxilla would be restored with a BruxZir Full-Arch Implant Prosthesis and his mandible with an Inclusive Locator Implant Overdenture. Fabri- cating his maxillary restoration The surgical phase of treat- ment called for the extraction of the patient’s remaining teeth, fol- lowed by the immediate place- ment of eight dental implants. Cone beam computed tomogra- phy (CBCT) scans were taken to posterior implants tilted to maxim- ise the anterior–posterior spread, avoid the sinuses and accommodate the patient’s bone limitations (Fig. 3). Osteotomies were created for the placement of four mandibu- lar implants, as opposed to the min- imum of two required for a Locator overdenture. This would enhance retention of the overdenture while affording the possibility of upgrad- ing to a ixed restoration at a later time. After the creation of the oste- otomies, the implants were placed (Figs. 4a & b). Inclusive Multi-Unit Abut- ments (Glidewell Direct) were at- tached to the maxillary implants, correcting for the divergent angu- lation of the implants. This would both position the restorative plat- form in a manner that would situ- ate the screw access holes of the eventual prosthesis toward the lin- gual aspect and allow for a molar– molar restoration (Fig. 5). Note that patients with terminal dentition presenting for treatment are com- monly anxious about losing their teeth and the effect this will have help determine the optimal place- ment of the implants within the available bone and away from the patient’s vital oral anatomy. Eval- uation of the CBCT scan deter- mined that there was suficient height, width and quality of bone to place the implants in the ap- propriate locations and angula- tions via freehand surgery. Four ø 3.7 mm Inclusive Tapered Im- plants (Glidewell Direct) would be placed in each arch to support the ixed maxillary restoration and the removable mandibular pros- thesis. At the surgical appoint- ment, the patient’s remaining teeth were removed, and a lap was raised to visualise the socket sites and areas of implantation. Bone levelling was performed on the patient’s upper arch to elevate the patient’s smile transition line above the upper lip. The maxillary osteotomies were positioned to facilitate an all-on-4 coniguration, with the 13b

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