Full mouth rehabilitation with implant supported restorations

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On reviewing the case report presented by Dr. Udatta Kher, a visual essay of a full mouth implant supported restoration for a 62-year-old healthy non smoker male patient, editorial board member Dr. Ali Tunkiwala had some interesting queries.

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Full mouth rehabilitation with implant supported restorations

  1. 1. FULL MOUTH REHABILITATION WITH IMPLANT SUPPORTED RESTORATIONS A case report by Udatta Kher
  2. 2. The following is a visual essay of a full mouth implant supported restoration for a 62- year- old healthy non smoker male patient
  3. 3. FIG 1: Baseline situation FIG 3: Extraction of teeth and flapless implant placement FIG 2: Pre- operative radiograph showing satisfactory bone condition in mandible and highly compromised bone in the maxilla FIG 4: Flapless implant placement. Bio- horizon, FIG 5: Sinus graft for maxillary first left molar region with Novabone (Calcium PhosphoSilicate) putty with simultaneous implant placement
  4. 4. FIG 6: Implant positions for maxillary anterior region FIG 8: Bio- horizon tapered internal implants placed in sockets of teeth FIG 7: Ridge expansion using bone expansion screws
  5. 5. FIG 20: Jaw relation FIG 21: Verification jig in resin for fit of the framework
  6. 6. Q. Why was a flapless approach chosen for implants in the mandible?  The CBCT showed good volume of bone in the mandible at the sites where implants were planned. The flapless implant placement is minimally invasive and the postoperative recovery after the procedure is very rapid. The patient’s existing denture served as a stent and the 2 extraction sockets of teeth # 33 and 43 provided a guideline for accurate implant locations.
  7. 7. Q. What were the challenges faced in the surgery for maxillary implant placement? The bone volume in the maxilla in the sites of previous extraction was very deficient. Hence bone manipulation and augmentation procedures were used simultaneously to place implants in the maxilla. The left maxillary sinus was grafted to increase vertical height of bone. The anterior maxilla had reduced width of bone. Hence, bone expansion and GBR procedure using Calcium phosphosilicate putty and collagen membrane was performed at the location of teeth #12 and 22. Since the extraction sockets of teeth # 13, 14, 15 and 23 were found suitable, implants were placed in those sockets and the gaps were grafted with CPS putty.
  8. 8. Q. What prosthesis was the patient wearing during the healing phase? An immediate denture relined with a soft denture reliner was used as an interim prosthesis.
  9. 9. Q. Why were the mandibular and maxillary maxillary prosthesis made at different times? The mandibular implants were placed in good non grafted sites. Hence, they were ready for loading after 2 months. Since the maxillary sites were compromised and needed extensive grafting, the maxillary implants were loaded after 6 months.
  10. 10. Q. Why were different impression procedures chosen for the two arches? The mandibular implants were almost parallel to each other. A closed or an open tray technique is suitable in such cases. In this case we chose an open tray impression in a stock tray without splinting the impression posts. Due to the configuration of the maxillary bone, the implant angulations have a few degrees of divergence. Hence an open tray impression procedure with a custom tray and splinted impression posts was used to minimize errors in transfer of the implant prosthetic platform.
  11. 11. Q. How was the jaw relation recorded? A screw-retained base with a wax rim was made to record the jaw relation. The firm base rested on the implants and not the soft tissue. This helped in reducing errors while recording the relation of the maxilla against the mandibular fixed prosthesis.
  12. 12. Q. Why were screw retained restorations chosen? The screw-retained restorations are easier to maintain since they can be retrieved. That is a big advantage while making multi implant prosthesis.
  13. 13. Q. Why were different materials chosen for the mandibular and maxillary prosthesis? Porcelain fused to metal screw-retained bridge without any flanges was chosen in the mandible for better maintenance. A hybrid denture was chosen the maxilla to compensate for the loss of the hand and soft tissue. The labial contour needed to be optimum for adequate lip support. A screw retained hybrid denture with acrylic teeth served this purpose. Also, since the maxillary bone was of poorer quality and had grafted sites, a softer material like acrylic was chosen to reduce occlusal stresses transmitted to the bone.
  14. 14. Q. Why was the mandibular prosthesis made in 2 pieces? The terminal implants in the mandible were placed bilaterally in the region of the first molar. Flexure of the mandible while opening and closing would have created stress in the prosthesis which would eventually lead to bone loss around the implants. The prosthesis was split between right canine and first premolar region to minimize this effect.
  15. 15. Q. How will the patient maintain the prosthesis?  The patient has been advised to use an oral irrigation device for cleaning the prosthesis and interdental brushes to clean the underside of the bridge. The mandibular prosthesis being a flangeless PFM prosthesis will be easier to maintain compared to the one in the maxilla. During a 6 monthly recall, both the prosthesis will be removed for cleaning and better maintenance.

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