|Year : 2012 | Volume
| Issue : 2 | Page : 116-121
A pragmatic combinational approach to full-mouth rehabilitation
Mantena S Raju, Sruthima N. V. S. Gottumukkala
Department of prosthodontics, Vishnu Dental College, Bhimavaram, India
|Date of Web Publication||4-Sep-2012|
Sruthima N. V. S. Gottumukkala
Department of prosthodontics, Vishnu Dental College, Bhimavaram
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Restoration of a partially edentulous geriatric patient's mouth with complete esthetic and functional reconstruction may present numerous problems to the dental professional. The major concerns include centric relation, esthetics, phonetics and the patient's occlusal vertical dimension. Taking this into consideration this article tries to explain in detail the step-by-step procedure in treatment planning, surgical and prosthetic aspects taken to completely rehabilitate a 65-year-old partially edentulous patient using a combination of implants, fixed and removable prosthesis. The completed treatment was successful both subjectively and objectively, with the patient reporting good results even after 2-years post-treatment.
Clinical Relevance to Interdisciplinary Dentistry
- A multidisciplinary approach to provide improved esthetics, function and occlusal stability.
- A combinational approach by a team of prosthodontist, periodontist and an endodontist helped in attaining diagnosis and a desirable outcome.
- Restorative phase had an amalgamation of removable, fixed and implant-supported prosthesis.
Keywords: Cast partial denture, dental implants, full-mouth rehabilitation, implant retained denture
|How to cite this article:|
Raju MS, Gottumukkala SN. A pragmatic combinational approach to full-mouth rehabilitation. J Interdiscip Dentistry 2012;2:116-21
| Introduction|| |
Loss of natural teeth results in both esthetic and functional deficits as the age of the patient advances. This leads to significant reduction in the patient's quality of life and self image perception. Therefore offering the correct treatment options to the patients losing their teeth either due to extraction or as a natural physiologic process is an important aspect of comprehensive patient treatment. In today's dental practice many published papers suggest the application of implants in the management of partially edentulous patients which can serve as abutments for either single crowns or fixed partial denture. , There are numerous studies using a combination of implants and removable prosthesis.  However, a combination of implants and fixed prosthesis was found to be difficult to implement. , These contraindications can be based on either the patient's medical condition, or surgical concerns such as close proximity of the sinus floor or mandibular nerve. In view of all these considerations a pragmatic approach to full-mouth rehabilitation of a geriatric patient using a combination of implants, fixed and removable prosthesis was planned in this present case report.
| Case Report|| |
A 65-year-old male patient reported to our dental clinic with a chief complaint of missing teeth and unable to masticate. After initial consultation, complete extraoral and intraoral examination of the patient was done. It helped us to diagnose the collapsed extraoral facial profile [Figure 1]. Intraoral examination revealed the presence of partially edentulous upper and lower arches, with moderately resorbed maxillary arch in the premolar and molar regions [Figure 2]a,b. During the initial visit, appointment was scheduled for complete medical examination, radiographs (including panoramic and full-mouth series of IOPA), and impressions for study models, bite registration and face bow transfer, as well as photographs. Complete medical and hematological examination revealed no absolute contraindications to any therapeutic or surgical modality. However, the patient reported an acute attack of sinusitis about 2 weeks prior to the first appointment. Panoramic radiograph revealed closed proximity of the sinus floor to the alveolar ridge [Figure 3]. Complete intraoral condition was analyzed and different treatment options ranging from conventional removable prosthesis to two-stage implant placement with sinus augmentation in the maxillary posterior region was planned and discussed with the patient. However, although there were no absolute contraindications for sinus augmentation, the acute sinusitis attack was considered as a relative contraindication in addition to the patient's unwillingness for invasive surgical procedures. In view of the above said considerations a combination of fixed and removable prosthesis including implant placement in the lower anterior region was planned. The preoperative planning was conducted with a diagnostic wax up to have an idea of the treatment objective. This model was duplicated to fabricate surgical stents in the lower anterior region that would serve as reference during surgical procedures for implant placement.
|Figure 2: (a) Intra-oral examination showing moderately resorbed maxillary arch and multiple missing teeth (b) Intra-oral examination showing moderately resorbed mandibular arch|
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|Figure 3: Pre-operative OPG showing close proximity of the sinus floor in the maxillary posterior quadra|
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Vertical dimension of the patient was not satisfactory as there were no stable opposing occlusal contacts. In the current scenario for establishing vertical dimension at occlusion initially, we determined the incisal edge position and lip support based on the patients upper lip support and visibility. Occlusal plane was related to the campers plane as we were replacing the maxillary posterior teeth with removable partial denture. Then we determined vertical dimension at occlusion by measuring vertical dimension at rest minus 2-3 mm to get an estimated VDO.
The preoperative treatment plan was made keeping in mind the end result of the treatment, to be harmonious with biological, esthetic and functional aspects. The treatment plan involved
- Periodontal therapy including scaling and thorough root planning.
- Fixed partial denture prosthesis including crowns and bridges in the upper anterior and lower posterior sextants
- Implant supported prosthesis in the lower anterior sextant
- Removable prosthesis in the upper posterior sextants
- Supportive periodontal therapy including maintenance and recall visits
As a first step of treatment in consideration of the patient's periodontal consideration full-mouth subgingival scaling was performed and re-evaluated after a period of 1 week. Thorough root planning in two divided appointments was performed which showed complete reduction in the gingival inflammation, reduction in the pocket depth and improved health of the supporting tissues.
The tooth no's 13, 23 and 24 were planned to serve as abutments for the fixed partial denture in replacement of maxillary anteriors. Abutment were clinically sound without any periodontal or periapical complications. It would have been ideal if the span of the edentulous arch was smaller as the load on each abutment could be decreased considerably. Crown preparation was done and impressions were made using Addition silicone impression material (Aquasil Soft putty/Regular set, DENTSPLT DE TREY GmbH, germany). Provisional restoration with autopolymerizing resin (DPI-RR Cold Cure, DPI INDIA) were given for the prepared crowns. Metal try in was performed and the final restoration was cemented using type I glass ionomer cement (GC corporation, Tokyo) [Figure 4].
In the mandibular anterior region four two-staged implants were planned for placement to serve as abutments for fixed partial denture in the replacement of 6 lower anteriors. In anatomical diagnosis mental foramen were radiographically located in relation to the apices of 1 st premolar region. They were approximately located 28 mm from the midline of the mandible and 12-14 mm from the lower border of the mandible.  On assessing periapical radiographs and OPG there was no presence of anterior loop. Bone mapping did not reveal any bony defects in the sites chosen for implant placement. Vital signs were checked and consent had been obtained from the patient prior to the surgery. Patient was advised for prophylactic antibiotics i.e., Amoxicillin 1 g in 1 hour prior to the surgical procedure. Extraoral disinfection with 5% povidone iodine and preprocedural rinse with 2% povidone iodine for 30 sec was performed. Local anesthesia was administered using lignocaine 2% with 1/100000 epinephrine. Crestal incision was made 2 mm away from the midcrestal region toward the lingual side using no.15 bard parker blade and full-thickness mucoperiosteal flaps were elevated. Initial osteotomy preparation was started with a round bur and completed up to 3.5 mm. 4.2-mm diameter root form Endosseous implants (ZIMMER Tapered Screw-Vent, TSV-MTX Zimmer Dental Inc) were placed in the planned position and covered with healing screws [Figure 5]. The implants achieved good primary stability. After necessary radiographs to verify alignment and depth, the flaps were approximated with 4-0 vicryl sutures (vicryl*plus anti bacterial sutures, ETHICON Inc., india) and covered with periodontal dressing (Coe-Pak, GC India). Patient was prescribed antibiotics for 5 days and analgesics postsurgery. Sutures were removed after 10 days. During the healing phase an interim removable prosthesis was given for a period of 4 months [Figure 6]. During the healing phase appointments were scheduled for bridge preparation in the mandibular right posterior region.
Tooth 47 was having an amalgam restoration. While 45 was having mild attrition, which was correlating to the patient's age. Abutments crown root ratio was satisfactory according to antes law. Crown preparation was done on tooth no's 44 and 47, and gingival retraction cords (Ultrapak Cord #00, Ultra-Pak Inc., PA) were used for gingival retraction and impressions were made with custom tray using addition silicone impression material (Aquasil Soft putty/Regular set, DENTSPLT DE TREY GmbH, germany)and provisional restorations with autopolymerizing resin (DPI-RR Cold Cure, DPI INDIA)were given for the prepared crowns. The patient was then scheduled for a refinement visit before finalizing the restorations. Final restoration was cemented after patient's approval using Type I glass ionomer cement (GC Gold Label 1, GC India) [Figure 7].
After the healing period of 4 months, circular incisions were given in the implant sites to expose the healing abutments and impression copings (ZIMMER Tapered Screw-Vent, TSV Zimmer Dental Inc) were attached [Figure 8] for the impression procedure and thoroughly checked for proper seating [Figure 9]. Impression tray was modified for fixture level impression and impression was made with addition silicone after which implant analogues were attached for impression copings. healing abutments (ZIMMER Tapered Screw-Vent, TSV Zimmer Dental Inc) were then kept in place for 1 week and later abutments were fixed in the oral cavity [Figure 10]. Crown preparation was done on tooth no's 35, and 36. Gingival retraction with retraction cords (Ultrapak Cord #00, Ultra-Pak Inc., PA) was done and impression of the abutments and prepared teeth were made. The working casts were prepared and mounted on a nonarcon, semiadjustable articulator (Hanau Wide-Vue Arcon 183-2, WATER PIK, INC., US) using face bow records (HANAU™ Spring-Bow, WATER PIK, INC., US). The centric relation, intercuspal position and vertical dimension were also transferred to the articulator from the patient, using a polyvinyl siloxane putty bite. During metal trial, fit of the castings and occlusal clearance were checked. A bisque trial was done to confirm fit, shade and occlusal parameters. Later, the final metal ceramic prosthesis was constructed. The final restorations were then tried in the mouth and presented to the patient for approval. After occlusal adjustment, luting of restoration was done with Type I glass ionomer cement (GC Gold Label 1, GC India) [Figure 11].
In maxillary posterior sextants implant prosthesis was ruled out due to the close proximity of the sinus floor and the patient's unwillingness for invasive surgical procedures. Rest seat preparation was done in the maxillary arch on tooth no's 13, 24, and 27. Tooth 24 was having slight bone loss but it does not have any clinical mobility. So, it was selected as an abutment for cast partial denture along with 27 and 13. Tooth 24 also was slightly distally inclined compared to the other teeth in the same arch. Guide planes were also prepared on 24 and 27. Impressions of both the upper and lower arches were made using addition Addition silicone impression material (Aquasil Soft putty/Regular set, DENTSPLT DE TREY GmbH, germany) and alginate (Tropicalgin Zhermack, Italy. Cast partial denture was fabricated and inserted in the maxillary posterior region [Figure 12]. The patient was then instructed on the importance of a 3-month recall during the first year to monitor the implant site. Recall appointments were given for cleaning and maintenance of the prostheses at every 3-month intervals during the first year and every 6 months later.
|Figure 12: Cast partial denture inserted in the maxillary posterior sextant|
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| Discussion|| |
In the current treatment procedure extensive restorations were required to optimize the patient's occlusion. Therefore, a reorganized approach is needed as the present intercuspal position (ICP) is unacceptable and needs to be changed. The ICP is developed at the centric relation position of the mandible. This provides an even and stable occlusion and also ensures that there were no pathological deflective contacts. Therefore, most of all full-mouth rehabilitations tread this approach as it restores the structural and functional integrity of the dental arches that are compromised due to multiple missing teeth. Proper understanding of the bio-mechanics and a pragmatic approach to restoration of edentulous ridge using a simple cast partial denture framework can aid in a successful biological and functional rehabilitation.
Rehabilitation of patient's with missing bilateral posterior teeth and moderate to severe bone loss, presents one of the most complex treatment modalities due to shift in the sinus floor position, hindering the replacement with fixed prosthesis i.e., implants. Sinus floor augmentation with wide range of biomaterials and bone replacement grafts using various techniques presents a challenging treatment option in such conditions. ,, However, in this case the patient's unwillingness to invasive surgical procedure and the relative surgical contraindication knocked out the fixed treatment option in the maxillary posterior sextants. Therefore cast partial denture was planned as an alternate treatment option. The success of cast restorations is linked to patient-related factors such as maintenance of proper oral hygiene and eating habits, and treatment plan-related factors such as occlusal adjustment and stability in addition to the technique and materials employed. ,
According to Dawson, anterior teeth play a dominant role in establishing the functional path that the mandible can travel. Therefore, the position and contours of lower anterior teeth should be the starting point of occlusal design as they are the beginning of functional movements that establish anterior guidance and the envelope of motion.  Taking this into consideration a segmental or quadrant wise rehabilitation with anterior guided occlusal scheme has been followed. However, lower incisal edge position and anterior guidance was satisfactorily attained with our treatment plan. Thus, in this case successful osseointegration of the implants placed in the lower anterior region and the long term stability of these implants are the prime factors which played a role in the occlusal rehabilitation.
| Conclusions|| |
Creating the perfect smile along with health is a challenging procedure that requires meticulous understanding of the patient's needs and treatment planning. The integration of different types of prosthetic replacement procedures in complex full-mouth rehabilitations requiring multiple restorations especially in a geriatric patient can be a challenging task for the dental clinicians. It requires thorough knowledge, understanding, and creativity to fulfill the patient's functional and esthetic requirements. In the present case report the use of three different prosthesis and different techniques posed a challenge in achieving natural esthetic appearance, and in satisfying biomechanics and function as well as the patient's ultimate desires. However, although technically challenging, this approach facilitated a more conservative treatment in terms of using cast partial denture in the maxillary posterior segment and achieving stability. Interdisciplinary approach to treatment planning and treatment sequencing, communication between all members of the interdisciplinary team, and a good understanding of the various biomechanics are the key to successful result of this type of comprehensive approach. Thus, a successful esthetic and functional result using three different types of prosthesis was achieved in the presented full-mouth rehabilitation.
| References|| |
|1.||Ericsson I, Lekholm U, Branemark PI, Lindhe J, Glantz PO, Nyman S. A clinical evaluation of fixed-bridge restorations supported by combination of teeth and osseointegrated titanium implants. J Clin Periodontol 1986;13:307-12. |
|2.||Van Steenberghe D. A retrospective multicenter evaluation of the survival rate of osseointegrated fixtures supporting fixed partial prostheses in the treatment of partial edentulism. J Prosthet Dent 1989;61:217-23. |
|3.||Binkley TK, Binkley CJ. A practical approach to full mouth rehabilitation. J Prosthet Dent 1987;57:261-6. |
|4.||Battistuzzi PG, Van Slooten H, Kayser AF. Management of an anterior defect with a removable partial denture supported by implants: A case report. Int J Oral Maxillofac Implants. 1992;7:112-5. |
|5.||Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical complications in fixed prosthodontics. J Prosthet Dent 2003;90:31- 41. |
|6.||Juodzbalys G, Wang HL, Gintautas. Anatomy of Mandibular Vital Structures. Part II: Mandibular Incisive Canal, Mental Foramen and Associated Neurovascular Bundles in Relation with Dental Implantology. J Oral Maxillofac Res 2010;1:1-10. |
|7.||Artzi Z, Nemcovsky CE, Dayan D. Nonceramic hydroxyapatite bone derivative in sinus augmentation procedures: Clinical and histomorphometric observations in 10 consecutive cases. Int J Periodontics Restorative Dent 2003;23:381-9. |
|8.||Wallace SS, Froum SJ. Effect of maxillary sinus augmentation on the survival of endosseous dental implants. A systematic review. Ann Periodontol 2003;8:328-43. |
|9.||Mazor Z, Horowitz RA, Del Corso M, Prasad HS, Rohrer MD, Dohan Ehrenfest DM. Sinus floor augmentation with simultaneous implant placement using Choukroun's platelet-rich fibrin as the sole grafting material: A radiologic and histologic study at 6 months. J Periodontol 2009;80:2056-64. |
|10.||Huynh NT, Rompre PH, Montplaisir JY, Manzini C, Okura K, Lavigne GJ. Comparison of various treatments for sleep bruxism using determinants of number needed to treat and effect size. Int J Prosthodont 2006;19:435-41. |
|11.||Parker MW. The significance of occlusion in restorative dentistry. Dent Clin North Am 1993;37:341-51. |
|12.||Dawson PE, editor. Functional Occlusion: From TMJ to Smile Design. St. Louis: Mosby Elsevier; 2007. p. 429-52. |
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