full mouth rehabilitation process using non-submerged type implant[1]_14

7/30/2019 Full Mouth Rehabilitation Process Using Non-Submerged Type Implant[1]_14

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Full Mouth Rehabilitation Process using Non-

submerged Type ImplantEom Seung-ilDirector, Busan World Dental Clinic

Case report

The patient almost had edentulous jaw and the teeth supporting RPD was separated from the extraction sockets.

The patient has used denture for 6 year. Figure 2 and 3 shows very interesting cases that the abutments weresupported by the extraction sockets.

The patient strongly wanted the restoration of prosthetic implant considering chewing efficiency and appearance.

Two treatment methods were suggested: an implant supported overdenture that a total of 4 each implant is

placed to the anterior region of maxillary and mandible; a fixed prosthesis with 7 to 8 implant placement. The

fixed prosthesis was selected considering patients age in his late 40s and psychological burden.

Fig. 1. Preoperative

radiography. The bonequality and volume showed

the moderate condition for

the implant placement in a

whole.

Fig. 2 and 3. The RPD used before procedure. The retention and

stability of RPD was secured by the abutment which was maintainedby the inside of extraction sockets.

Fig. 4. Before the main implant

procedure, mini-implant was

placed to the anterior of

maxillary and mandible for thetransitional denture to be used

during healing period.

Fig. 5 and 6. The impression was taken under the intraoral placement

of temporary implant. Then the metal splint was made on the upper

part of temporary implant of working cast.


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Fig. 7. The metal splint was intra-

orally adhered using resin cement.

The head of temporary implant

projected to the upper part of metal

splint was removed by bur. The height

of metal splint should be 4mm or more

for securing appropriate retention and

stability.

Fig. 8. After scraping out the inside of transitional

denture, relining on the upper part of metal splint

was made using soft relining material. Firmly

maintained through the connection with temporary

mini-implant, the metal splint improves the

retention and stability of upper denture and extends

the life of temporary implant during healing period.

In addition, the metal splint helps to reduce the

transmucosal loading imposed to the main implant

to be placed to the posterior region.

Fig. 10. Selection of implant

suitable for the bone width and

placement to mandible.

Fig. 9. A non-submerged type

implant placement to the

posterior region of maxillary.

Fig. 11. Following the connection of

solid abutment to the maxillary and

mandible 3 months and 2 months

after implant placementrespectively, the anterior temporary

implant and metal splint was

removed. A temporary fixed

prosthesis was made on the upper

part of solid abutment.

Fig. 12. Temporary fixed prosthesis Fig. 13. Mini-implant (MDL 2

x 13mm) was placed to the

anterior of mandible for

additional support.


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Fig. 14 and 15.

Impressionmaking for whole

maxillary and

mandible wasmade 2 months

after the

placement of

mini-implant.

Fig. 16 to 19. The recordbase was made on the

working cast using GC

pattern resin. The record

base acts as the reference

point of the

determination of

intraoral verticaldimension of occlusion

and taking centric

position.

Fig. 20 and 2. Taking vertical dimension of

occlusion and centric position using record base.

Fig. 22. Mounting the working cast of maxillary

and mandible on the semi-adjustable articulator.

Fig. 23 to 25. The wax-up was primarily made. The canine protected occlusion was selected as

occlusal scheme.


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Fig. 26. Drawing of an circular arc on the occlusal

analyzer to form a appropriate plane of occlusion. The

plane of occlusion was formed using the crossing of

anterior and posterior circular arc as a reference point.

Fig. 27 to 29.The occlusion plane completed on the wax-up.

Fig. 30 and 31.

Marking proper

positions ofbuccal, lingual

cusp, central fossa

of lower teeth on

the wax-up.


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Fig. 32 to 38. Evaluation of the

required elements such as the length

of teeth, midline, occlusal scheme,

positional relationship betweenteeth, vertical dimension of

occlusion, and centric position

following intraoral test of wax-up.

Fig. 39 to 41. Evaluation of elements as the midline, plane of occlusion, length of

teeth during the intraoral insertion of wax-up.

Fig. 42 and 43. Confirmation of proper formation of vertical

dimension of occlusion through the evaluation of the tension

level of facial muscle, pronunciation, freeway space, and several

facial reference points.

Fig. 44. Once more taking of the

centric position on the wax-up

using gauge.


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Fig. 45 to 48. Completion of the

wax-up using newly taken centric

position. Making a jig with acrylic

resin coating on the upper part of

completed wax-up. The jig greatly

helps to coat porcelain due to itsaccurate reproducibility of

completed occlusal plane, cusp

angle, and the size of occlusal

surface.

Fig. 49 to 52. Making an index jig

on the completed wax-up using

putty impression material. This

index jig is referred to theporcelain depth and correct teeth

position in making the frame

work of definitive restoration.

Fig. 53. A cut back process was

made on the wax-up using

index jig.

Fig. 54. The completed wax-up

for making framework.


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Fig. 55. Adhesion of the sprue to wax-up Fig. 56. The completed

framework of maxillary and

mandible.

Fig. 57 and 58. Inspection of the fitness with the intraoralinsertion of completed framework.

Fig. 59. The framework wasmade to maintain the cement

and the fit checker was used to

evaluate the inside fitness.

Fig. 60 and 61. Following thefitness evaluation, the bite was

taken through the final

evaluation of vertical

dimension of occlusion and

centric position (Futar D

Occlusion).

Fig. 62. The porcelain build-upprocess on the upper part of

mandible using jig.


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.

Fig. 63. The occlusal surface of

completed definitive restoration

The size of occlusal surface is

smaller than natural tooth and

the cusp angle is very flat. This

was designed to protect

excessive lateral pressure on the

implant.

Fig. 64. The porcelain build-up

process on the framework of maxilla

based on the completed mandibular

porcelain.

Fig. 65 and 66. Evaluation of the proper formation of canine protected occlusion using articulator. Themaxilla is in the state of bisbaque: the pre-stage of the completion of porcelain.

Fig. 67 to 71. The occlusal adjustment was preformed with the intraoral insertion following the final

evaluation of elements in connection with the appearance and functions.


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Fig. 72 to 74. The delivery of definitive prosthesis.

Definitive restoration for maxillary and mandible was made as one-piece type. Due to the mandibular

flexure, the anterior and posterior region of mandible are sometimes separately fabricated. Otherwise, key &

keyway are attached between front and molar tooth to minimize the transmission of the movement ofmandibular posterior region.

Fig. 75. The panoramic viewof completed definitive

restoration.


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The success and failure of implant applied full mouth rehabilitation depends on how we properly applied the

required elements of prosthesis.

Under the situation without natural teeth, it was difficult to resemble its original state as closely as possible.

Another problem lay in how fast the patient adapted to new fixed prosthesis because he had used the RPD for a

long time.

1. Why we used the temporary mini-implant?

The temporary mini-implant was placed to the anterior of maxillary and mandible to minimize the pressure by

denture after the main implant placement. The metal splint was also prepared to minimize the movement of

transitional denture. The better method is to make temporary fixed prosthesis following the implant placement

between the spaces of main implants; we had no choice but to take other method because this case had no

sufficient spaces for the enough number of temporary implant placement to make fixed prosthesis between main

implants.

2. How many implant placements are required to the full mouth rehabilitation in case of edentulous jaw?

A total of 8 to 10 and 6 to 8 implant placements are generally needed for the maxilla and the mandible

respectively. However, the number can be adjusted in accordance with the condition of bony quality. It is

desirable to place the implant to the posterior region rather than anterior region as practicable as possible. This

may be the attempt to minimize the aesthetical loss caused by the implant placement to the anterior region.

3. How many units consist of the restoration for desirable full mouth rehabilitation?

In case of maxilla, one-piece restoration is desirable for the rehabilitation due to it splint effect if there is no

problem with implant path.

If there is difficulty in dental technology, key & keyway(precision attachment) is attached between anterior and

posterior region to provide the convenience of dental processing. The opening and closing of mouth by

mandible generates the difference of area in posterior region (mandibular flexure). The following methods may

be applied to the mandible to allow the movement of posterior region: to divide each anterior and posterior

region into three equal parts; to attach key & keyway (semi-precision attachment) between anterior and posterior

region; to attach key & keyway(semi-precision attachment) to the middle of mandible.

4. What material is used for the posterior occlusal surface?

In case of the formation of metal occlusal surface in the posterior mandible, it is desirable to cover the porcelainto avoid the exposure of metal through laughing laud or speaking. The fracture of porcelain can be prevented

by making metal occlusal surface on the opposing posterior maxillary.

In case both occlusal surfaces are made of porcelain, it is easy to repair poor occlusion while the sound touching

each other during mastication may generate the sense of being offended. This phenomenon generally happenswhen vertical dimension of occlusion is higher than allowed freeway space. This can be settled by the intraoral

adjustment of occlusion if the difference is small. However, all porcelain should be removed and repeat the

porcelain build-up process from the very first if the difference is big. Setting up of vertical dimension of

occlusion is important to that degree.

5. What occlusal scheme should be set for the full mouth rehabilitation?Likewise the natural teeth, the canine protected occlusion should be prepared for the protection of posterior teeth

when guiding if the implant is placed to the canine region. If this occlusal scheme is difficult due to the position

of implant placement, the occlusal morphology with anterior group function can be made. It is desirable to makeguidance in the anterior region to minimize the occurrence of the possible occlusal problems in connection with

implant.

full mouth rehabilitation process using non-submerged type implant[1]_14

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