1An alternative prosthetic solution for the loss of three of six maxillaryimplants: a case reportHakan BİLHAN1 and Semra CAN21 Dr.med.dent., Istanbul University, Faculty of Dentistry, Department ofRemovable Prosthodontics2 med.dent., Istanbul University, Faculty of Dentistry, Department of RemovableProsthodonticsCorrespondence Address:
2AbstractPlacement of implants is generally a successful treatment modality. However,implant losses can cause difficulties in prosthetic treatment. While a singleimplant loss does not change the treatment course by itself, loss of more thanone implant can make a fixed restoration, which was promised to the patientwhen the treatment plan was initially outlined, impossible to achieve.This article describes a case in which three maxillary implants were lost and adifferent prosthetic solution for the situation was applied. Since the 60-year-oldfemale patient insisted on a fixed denture, at least anteriorly, a detachableanterior part which was connected with Bego’s Ancora® precision attachments tothe cast framework denture was constructed. The 6-month result wasencouraging, but to be able to draw clinically meaningful conclusions about thereliability of this method, a longer observation period with more cases will benecessary.Key words: zirconium, upper detachable denture, precision attachments, implant prosthesis, cantilever
3INTRODUCTION restorations. The implant in regionPlacement of implants is generally a #26 was moving, and since it wassuccessful treatment modality. not osseointegrated, the implant wasHowever, implant losses can cause removed. Thus, the treatment of thereal dilemmas from time-to-time. patient was completed with a fixedWhile a single implant loss does not prosthesis and 5 implants.change the treatment course by Individually prepable Ti-design®itself, the loss of more than one abutments were selected for theimplant can make a fixed restoration, maxilla, and Direct Abutment®‘supon which the treatment plan was (AstraTech®) for the mandibula.initially based, impossible to achieve. Initially, the bridges were cemented temporarily and following a 1 monthTHE CASE period without complaints, they wereAfter devising a plan for a 60-year- cemented with polycarboxylateold female patient following the cement (Adhesor® Carbofine;extraction of all maxillary and SpofaDental / A Kerr Company,mandibular teeth, except #43 and Prague, Czech Republic).#44 (Figure 1), lower and upper Approximately 3 months later, whenimmediate dentures were delivered. the patient came back with aFollowing a 3-month healing period, decementation problem of the6 implants (AstraTech®, Mölndal- maxillary restoration, it was observedSweden) were placed in the upper that two more implants in the upperjaw. Six weeks later, 6 implants jaw were mobile. After these(AstraTech®) were placed in the implants were extracted, thelower jaw as well (Figure 2). Three situation (Figure 3) was explained tomonths later (approximately 5 the patient and the treatment planmonths of osseointegration time for was revised.the maxillary implants), the patient Of note, the patient’s spouse did notwas called for an impression-taking know that she was edentulous andsession for the prosthetic furthermore, the patient was initially
4promised to have fixed restorations. structure, including the holes, thusThe patient rejected a new operative solving the esthetic problem (Figureprocedure and did not want to accept 10).an alternative other than a fixed Considering that shrinkage wouldrestoration. The patient strongly occur during casting as a result ofdesired the visible part of the the large volume of the primaryprosthesis to be fixed, so an structure, which would transmitoverdenture with a bar was stress to the three implants, asuggested, which was rejected by passive-fitting body prepared with athe patient. In an effort to achieve CAD/CAM system was preferred andcomplete patient satisfaction, a fixed ZiO2 was chosen (ZIRKON ZAHN;detachable part between 13-24 Dentarius, Dental Innovation, Parma,(Figures 4 & 5) and a cast metal Italy).framework denture for the posterior After taking the impressions and(Figure 6) was planned. An occlusal having performed a verticalscrewed structure for the anterior dimension determination, a toothpart was planned in order to prevent setup and try-in was carried out indecementation due to the dislodging the next session, during which theforces during denture removal. agreement of the patient in terms ofHowever, considering the axial aesthetics and data that would be ofinclination of the remaining upper value to the laboratory, werejaw implants (Figure 7), thus making obtained. Then, the analogue of thethe occlusal screw holes visible on tooth setup was prepared with athe vestibular surfaces of the front pattern resin (Palavit G®; Heraeusteeth, a separate structure that Kulzer-GmbH, Hanau, Germany),would hold the precision attachments the teeth of the pattern resin wereand be carried on the Uni prepared (Figure 11a-c), and theAbutment®’s (AstraTech®) with precision attachments (Ancora®;occlusal screws was manusfactured Bego, Bremen,Germany) were(Figures 8 & 9). A secondary attached to the most distal parts ofstructure would cover the primary the infrastructure. Later the ZiO2
5infrastructure was prepared; copyingthe pattern resin model and thesuperstructure was also finishedusing ZiO2. The cast frameworkdenture with precision attachmentswas fabricated as well. With theporcelain processing on the Zirconsuperstructure, the restoration tookits final shape, and the patient alsoliked the esthetics, as well as thecomfort (Figure 12). The UniAbutment® screws were tightened,whereas the bridge was temporarilycemented (Temp Bond® - Kerr®).The patient was satisfied with theend result, and no problem occurredduring the next 6 months. Based onthe radiographic examination 6months later, no significant bone losshad occurred (Figure 13).
6DISCUSSION AND CONCLUSIONS osteocalcin could be an indicator ofThe loss rate in implants is generally faster bone resorption thanlow, but it has been reported that the expected. Weaker osseoadaptationnumber of losses are concentrated in should be expected with thesome patients.19 A similar situation stimulation of IL-1β (also calledhas been experienced in the osteoclast activating factor [OAF])Department of Removable Dentures and tumor necrosis factor alphaof Istanbul University, Faculty of (TNF-α). OAF has a significantDentistry. Sixteen of 19 losses of physiologic and homeostatic role in412 implants in a follow-up group the maintenance and repair of bonehave occurred in the maxilla. Fifteen tissue, however, it is not known toimplant losses out were in 5 female what extent OAF production ispatients (three failures in each physiologic and when OAFpatient). In common among these production is pathologic.2 Thepatients, apart from their gender, cytokines generally trigger osteoclastwas that their dental history showed formation and activation.16tooth loss due to periodontal If the patient has a history of severe,problems. In all 5 patients; type 4 chronic periodontitis,7 the possibilitybone, according to Lekholm and that the causative factors mayZarb,1 was observed during the negatively influence the success ofimplant surgery. implants is high.6We therefore questioned whether or In this case, zirconium was preferrednot this type of implant loss could be to manufacture the superstructure. Itrelated to the secretion rate of has been reported that zirconiumcytokines and/or a history of shows great strength, even in longperiodontitis history. Some patients structures,9, 13 and that the fracturehave increased inflammatory strength is comparable to metals.5,11, 12, 15, 17,18cytokine formation, therefore theyare more prone to peri-implant It is well-known that shrinkage ofinflammation. The presence of CAD/CAM manufactured structures,interleukin-1 beta (IL-1β) and thus the possibility that they cause
7contraction on the abutments, is In this case report, a treatmentlower than after casting procedures.8, alternative that can be used for14 patients with numerous implantIt is also known that distal extensions losses has been introduced. To becan transfer certain stresses to the able to draw clinically meaningfulimplants.3, 4, 10 However, if the distal conclusions as to whether theextension is the width of a premolar, method is reliable or not, a longerthe forces are expected to be observation period with more casestolerable. will be necessary.
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11Figure Legends one, including the holes, thus solving theFigure 1: The extraction of all esthetic problem. maxillary and mandibular Figure 11a: The tooth setup. teeth, except #43 and #44. Figure 11b: The analogue of theFigure 2: Panoramic x-ray of tooth set up was prepared 6 upper and 6 lower jaw with a pattern resin. implants. Figure 11c: The teeth of patternFigure 3: The maxilla after resin were prepared. loss of 3 implants. Figure 12: The patientFigure 4: Frontal view of the liked the esthetics, as well fixed detachable bridge as the comfort. between 13-24. Figure 13: In the radiographicFigure 5: Palatal view of the examination 6 months fixed detachable bridge later, no significant between 13-24. bone loss wasFigure 6: Cast metal observed. framework denture for the posterior part.Figure 7: The axial inclination of the remaining upper jaw implants.Figure 8: A separate structure which is carried on occlusal screw retained abutments.Figure 9: A separate structure that holds the precision attachments.Figure 10: A secondary structure covering the primary