Full Mouth Rehabilitation Process using Nonsubmerged Type Implant

Eom 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 were supported 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 bone quality 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 maintained by the inside of extraction sockets.

Fig. 4. Before the main implant procedure, mini-implant was placed to the anterior of maxillary and mandible for the transitional 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.

Fig. 7. The metal splint was intraorally 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. 9. A non-submerged type implant placement to the posterior region of maxillary.

Fig. 10. Selection of implant suitable for the bone width and placement to mandible.

Fig. 11. Following the connection of solid abutment to the maxillary and mandible 3 months and 2 months after implant placement respectively, 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.

Fig. 14 and 15. Impression making for whole maxillary and mandible was made 2 months after the placement of mini-implant.

Fig. 16 to 19. The record base was made on the working cast using GC pattern resin. The record base acts as the reference point of the determination of intraoral vertical dimension 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.

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 of buccal, lingual cusp, central fossa of lower teeth on the wax-up.

Fig. 32 to 38. Evaluation of the required elements such as the length of teeth, midline, occlusal scheme, positional relationship between teeth, 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.

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 its accurate 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 the porcelain 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.

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 intraoral insertion of completed framework.

Fig. 59. The framework was made to maintain the cement and the fit checker was used to evaluate the inside fitness.

Fig. 60 and 61. Following the fitness 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-up process on the upper part of mandible using jig.

. 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. The maxilla 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.

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 of mandibular posterior region.

Fig. 75. The panoramic view of completed definitive restoration.

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 porcelain to 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 happens when 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 make guidance in the anterior region to minimize the occurrence of the possible occlusal problems in connection with implant.