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Long-distance Communication Led to Beautiful Full-mouth Implant Case Results by Dr. Sam Sadati; and Luke Kahng, CDT

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Introduction

Clinician's Viewpoint

Our patient is a 52-year-old male with non-contributory medical history. He presented to the clinician's office for a consultation regarding his dentition, with major concerns that involved loose teeth along with recessed and bleeding gums (Fig. 1). His breath had a bad odor and some of his teeth were missing which was combined with pain while chewing. His smile was not aesthetically pleasing because the color of his teeth was yellow. They also had spaces in between them and he did not like their appearance. He was interested in improvement, but did not want to wear dentures or be without teeth for any period of time.

Before a comprehensive examination of his dentition, the clinician took a fullmouth series of X-rays, panoramic X-rays, study models, bite registration, face-bow records and also performed periodontal probings. The patient was then instructed to have an i-CAT taken for further diagnosis and treatment planning.

During the exam, the clinician discovered severe bone loss throughout the patient's mouth and that most of the teeth were non-salvageable. The few that could be saved were not conducive to helping achieve the excellent final results the patient was seeking. It was decided that the best treatment planning option was to extract all the teeth and provide him with as many implants as possible to support individual teeth since the patient wanted individual, non-splinted restorations if possible. The patient was not interested in a removable prosthesis so the clinician decided to provide him with a screw-retained fixed temporary roundhouse bridge fabricated from composite after the extractions. If surgery did not go according to plan, he would be given an immediate denture instead.

The patient was asked to come in with his wife for the treatment presentation at which time the possibility of different treatment options, advantages, disadvantages and risks were discussed. The goal was to maximize the number of implants to be placed surgically to support individual single teeth. The patient chose a treatment plan that included 11 implants on the maxillary arch and 10 implants on the mandibular arch. He had requested that he not wear any removable prosthesis - even as a provisional - so it was decided that he would be given a fixed temporary that was supported by the implants. That meant that after all implants were surgically placed, an impression had to be taken of the implants and sent to a lab to fabricate the fixed temp, and returned as soon as possible to be placed in the patient's mouth. The patient preferred to be without any teeth rather than to wear a denture for the short duration while his fixed temp was being fabricated in the lab.

However, the dentist determined that he would also make him a set of immediate dentures in case the plan did not go as expected. This way, he had a set of dentures to be used as a temporary if necessary. The dentist provided the patient with all the information about implant surgery and restorative prosthesis, questions were answered and the patient was provided with appropriate mouthwash and antibiotic prescriptions to be used prior to surgery. Appointments for the surgery and post-op checks were scheduled.

Case Study

On the day of surgery the patient's blood pressure and vital signs were checked. His blood was drawn so that the PRF (protein rich fibrin) could be extracted to be used in conjugation with his bone grafting to promote the healing process as well as to be used for the barrier over the bone graft. Prior to his surgery day, a tissue born bite registration was fabricated. Any other area of the mouth but the teeth was utilized in order to have a relationship of his mandible to his maxilla reference using his mounted models. This bite registration was extremely useful for mounting the patient's casts after all his teeth were removed.

On the day of surgery the patient was anesthetized with a combination of carbocaine, septocaine and marcaine. Then all of his maxillary teeth were extracted. Each socket was cleaned and scraped with a spoon excavator from all the granulation tissue. The osteotomies were done without the use of any surgical stent and correctly sized implants were placed based on pre-treatment planning, using the i-CAT image. After the implants were placed, the impression analogs were placed on top of each implant. Then Mineross bone graft was mixed with patient's own blood serum, extracted in the PRF process. The bone graft mixture was placed around the implants into the voids on the jawbone, covered with resorbable barrier and covered with PRF. Then resorbable sutures were utilized to bring the gingival tissue together and keep all the grafting material intact. The exact same procedure was done on the lower arch.

An open tray impression with PVS (polyvinyl siloxane) was taken for each arch. The impression copings were picked up inside the impression trays and healing caps were placed on each implant. Then the bite registration, previously fabricated from the mounted pre-op casts, were placed in his mouth and the area where the teeth were extracted was filled with viscous bite registration material to capture more anatomical points for accuracy. The entire procedure was done in one appointment starting on a Friday morning and by the time the case was finished it was afternoon. The patient was given post-op instructions and then was released to go home without any type of prosthetic or provisional in his mouth until Monday morning. Patient's impressions, bite registration and desired shade with several pictures were given to a local lab technician who had agreed to fabricate the temporaries on this case during the weekend. That lab technician produced a screw-retained fixed roundhouse composite temporary bridge on plastic temporary abutments for both arches and returned it to the dentist on Sunday afternoon.

The patient arrived on Monday morning and his healing condition was within normal limits. He had very light generalized swelling and he reported that he had minimal pain and discomfort. A liquid gel-type topical anesthetic was placed on his gingival tissue to make him more comfortable as the healing caps were removed and the maxillary provisional tried in first. The fit and the alignment of all temporary plastic abutments that were inside the roundhouse were checked and verified. Then the temporary was secured with the screw on each implant. The same steps were done for the lower arch. Several photos were taken of the provisional both outside and inside the mouth to aid in locating the screw access holes when it was time to remove the temporaries, as they would soon be filled with composite. The access holes were located in various places on the roundhouse and those which were visible to the eye aesthetically were filled with the same shade composite as the temporary. Those that were not visible were filled with opaque composite to be more easily located when the implants were all integrated and were ready for the process of final restoration.

The occlusion was then checked for any premature contacts in centric, and all excursion movements. The patient was released to come back for a post-op check in one week, one month and three months. The patient came back for all his post-op visits and his temps and overall oral health and condition were checked. There were no significant issues at any visiting time nor were there any emergency visits or calls from the patient during the integration period. The next visit was scheduled for six months from the surgery date and on that visit, once again, everything checked out to be within normal limits. Topical anesthetic was placed on his gums all around the temporary roundhouse and all the access holes were located and the plugs were removed. The screw retainers were then removed and the roundhouse temp came out. The tissue underneath was healed and formed desirably around each implant. However, on his lower anterior region he had gingival recession where bone had been lost on the ridge due to premature tooth loss. The integration of the implants was verified by using a torque wrench to make sure that they were not unstable or loose. Impression analogs where placed for taking the final impression. A custom tray for upper and lower impressions had been made previously from the models to be utilized for taking the final impressions. PVS material was used to take the final open tray impressions.

Another bite registration was taken using the same method as previously explained. A bite stick registration was taken for the lab to see the horizontal line and midline of the patient's face for aid in mounting the case in a correct orientation. Then the temporary roundhouse was put back in place in each arch just the same as before. An alginate impression of the upper and lower provisional and a bite registration of patient with the provisionals were taken. A shade was chosen by the patient and his wife for his final restorations.

At that time, all the impressions, bite registrations, casts of the temp and numerous photos that were taken before and during the procedure were sent to LSK121 Oral Prosthetics Dental Lab for fabrication of the final restorations. After the initial set up of the case in the lab, the technician and the dentist started discussing the type of material to be used. The goal was to provide the patient with the most natural dentition possible. It was therefore decided to use e.max as the final material of choice. The lab suggested the abutments in the anterior region be made out of gold to have a warmer and more pleasing look as the yellow shade of the gold would bleed through the e.max porcelain.

Laboratory Procedures

Because implant restorations are becoming more and more popular, techniques have improved and are much more compatible with each patient's situation. The issues encountered in the past, such as alignment or incorrect size, have largely been dealt with and solved in a much more efficient way. In the case of this particular patient, the geographical distance played a role in the way it was handled overall. But the results were still excellent due to the use of photos and close communication between the clinician and the technician via e-mail and phone.

As we view the right side of the patient's dentition (Fig. 2), we can see the occlusal shape and contour of teeth numbers 8, 9, 10 and 11, which required a 2mm reduction and 3mm to the incisal edge of the premolars for a Class I bite.

The temporization models served as a great tool for the beginning stages of the case (Fig. 3). The incisal edge was too short, it was noted, and would be reduced 1.5mm. The midline also needed correcting, something that would be corrected in the final restorations.

The clinician did a wonderful job of opening the vertical dimension of occlusion with this procedure (Fig. 4). He placed putty on the back side of the patient's dentition and soft-tissue areas of the mouth where there were not any teeth, took out the temporaries and filled the voids with viscous bite registration material. This is the best method for such a complicated, fullmouth case in order to produce a correct bite. The bite was translated by mounting the model on an AmannGirrbach articulator and registering an accurate vertical dimension.

The UCLA abutments were placed on top of the model to illustrate the in/out movement of the implants in order to coordinate and bring them into alignment (Fig. 5). The abutments were later cut with a diamond disc and waxed-up. Before casting, the technician needed to see which teeth were to be single restorations and which would be a bridge, largely for spatial reasons.

As mentioned, the abutments seen here on the model, were cast with gold (50 percent yellow precious) (Fig. 6) due to the fact that we wanted to make sure no gray shadow would show through at the margin of the anterior teeth. All the restorations were fabricated and the case was sent back to the clinician and the abutments tried in the mouth. There was indentation noted in the facial area (Fig. 7).

Back at the lab, the abutments were placed back on the model, and white precious copings with white opaque material were fabricated (Fig. 8). A second build-up of enamel was applied (Fig. 9). Maximizing the build-up, pink tissue design color was applied. Coordination of the anterior mandibular six teeth was measured from the cusp to cusp of each premolar (Fig. 10). Curves of Spee and Wilson were checked, as well, during this fabrication stage. A second enamel build-up was applied after contouring (Fig. 11) and then final glaze (Fig. 12). Note the canine rise in this view. On the cast model, the lower teeth display a pink tissue design, not too long but the right size for the patient's final restorations (Fig. 13). The final restorations, which were mostly all individual single units, except for the lower anterior with a three-unit bridge, were returned to the dentist in a few weeks time and were all checked for anything that was not acceptable or undesired prior to scheduling the patient. After making sure the restorations were made correctly, a cementation appointment was scheduled.

On the day of the cementation the patient was anesthetized with septocaine, the temps were removed and all the abutments carefully positioned, placed and tightened on the implants. As each restoration was individually placed, the margins and the fit were checked. All the restorations were placed on the implants together and various X-rays were taken to verify fit. Then the patient and his wife were asked to look at the smile to make sure they approved before final cementation. After confirmation, all restorations were cemented with temp bond for test driving. The dentist could also see if there was any area that needed later modification. Occlusion was carefully checked in detail and all the adjustments were made and the porcelain polished.

The patient was released that day and an appointment scheduled for three weeks out. The office made sure to call the patient to see if he had any concerns with his new restoration and that nothing was loose. The patient then came back in three weeks and reported that he was very comfortable with them and had no problem at all. The restorations were removed, the abutments and the inner side of all restorations were cleaned and etched with hydrofluoric acid, saline was placed inside them and they were cemented with dual-cure composite luting resin cement. All the excess cements were removed and cleaned carefully. The occlusion was checked again, noting there was no change from the time they were cemented with temporary cement. Upon immediate insertion, we are given a final smile view. Final color is a bleaching shade, perfect for the patient's coloring, teeth size and appearance (Fig. 14).

Alginate impressions of the restorations and a bite registration were taken for fabrication of an occlusal guard. The patient came back in three weeks for another post-delivery check. On that day his night guard was delivered and the final photos were taken.

Conclusion

The patient's objectives were met and he was very happy. The fact that he was very personable made this case go smoothly. He has the dentist's and the lab's gratitude for being able to handle a long and tiring procedure, leading to excellent aesthetic and functional results. It is always recommended that the dentist and lab technician have excellent communication about everything from material selection, color, contour, occlusion and the patient's desires and concerns in order to achieve the best possible results. Even though the distance between them was long, it was a great journey.

Author's Bio
Luke S. Kahng, is one of the world's finest and most accomplished lab technicians, specializing in high-end ceramic restorations. Luke has served on several major dental journal boards as a contributing member.

Luke invented the Chairside Shade Guide - Volumes 1 and 2 and then expanded the offering to a unique ceramic shade guide system named the Seasons of Life Selection. These valuable tools are used daily on a world-wide basis.

Luke is owner and President of his own lab, LSK121 Oral Prosthetics, one of the largest dental laboratories in the country, located in Naperville, IL.

He has published over 100 articles in major national dental publications. Additionally, Luke has authored several books, including Anatomy from Nature, The Aesthetic Guide Book, Smile Selection Plus CS3 Clinical Cases, and The Kaleidoscope Wax-Up Book. These books have been distributed throughout the world as must-haves for Dentists eager to gain more knowledge in their industry.

In 2014, Luke will publish another important milestone book, The Secret of Shade Guide Matching.
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