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Predictable prosthetic space maintenance during staged complete-mouth

rehabilitation

Article  in  The Journal of prosthetic dentistry · May 2017

DOI: 10.1016/j.prosdent.2017.03.026

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 CLINICAL REPORT

Predictable prosthetic space maintenance during staged

complete-mouth rehabilitation
Abdulaziz AlHelal, BDS, MS,a Sarah Bukhari, BDS,b Mathew T. Kattadiyil, BDS, MDS, MS,c Rami Jekki, DDS, MS,d
and Ankur Dahiya, BDS, MDS, MSDe

Complete-mouth rehabilita- ABSTRACT

tion is a complex treatment that
Staged complete-mouth rehabilitation to accommodate a patient’s financial constraints during
requires significant time and the course of treatment is presented. Clear acrylic resin added to the anterior cameo surface of the
commitment from both patient maxillary fixed complete denture (FCD) served as a space maintainer. The restoration of the
and clinician. The keys to suc- maxillary FCD addressed the patient’s chief complaint. By adding the space maintainer, supra-
cessful complete-mouth reha- eruption of mandibular anterior teeth and encroachment of the prosthetic space, which could have
bilitation are detailed treatment resulted in additional treatment, was avoided. During the second stage of the complete-mouth
planning and complete control rehabilitation, zirconia restorations were used to restore the mandibular arch to the maxillary
of the treatment.1,2 Higher FCD after straightforward removal of the space maintainer. This allowed a smooth transition after a
delay in treatment without having to modify the previous treatment. (J Prosthet Dent 2017;-:---)
treatment costs can be a pri-
mary reason for patients to refrain from seeking compre- CAM) interim restorations.27,29-33 This clinical report
hensive dental care.3-6 The cost of dental care can be a demonstrates a reversible cost-effective approach with
barrier to the consent for dental services that affects be- a staged complete-mouth rehabilitation involving a
tween 30% to 61% of the population.7 maxillary fixed complete denture (FCD) opposing a
A change that usually occurs in complete-mouth restored worn dentition.
rehabilitation is in occlusal vertical dimension (OVD).8
Restoring patients with loss of posterior support can
be clinically challenging because these patients tend to CLINICAL REPORT
9-11
have reduced OVD. Sometimes with decreased OVD A 61-year-old white woman sought care at the Loma
the interocclusal space is insufficient, which can further Linda University School of Dentistry, noting, “I am tired
complicate the rehabilitation process.10-14 When of having my upper implant bridge repaired, but I cannot
restoring such patients, the use of homogenous antag- afford to have all my teeth fixed at the moment”
onistic restorative surfaces is a consideration and is (Fig. 1A). Her dental history revealed that she recently
recommended to reduce wear.11,15-21 had 6 dental implants (NobelSpeedy Groovy; Nobel
When patient finances become an unexpected factor Biocare) placed in her completely edentulous maxillary
that delays treatment, long-term interim restorations are arch (Fig. 1B) and 3 dental implants in her partially
often indicated.11,22-28 However, complications might edentulous mandibular arch (NobelReplace Tapered;
develop with these restorations because of material Nobel Biocare). A fractured maxillary interim FCD
degradation, even with improved computer-assisted opposing a mandibular arch with teeth having moderate
design and computer-assisted manufactured (CAD- to severe attrition (Fig. 1C) resulted in reduced OVD.

a
Faculty, Department of Prosthetic Dental Sciences, College of Dentistry, King Saud University, Riyadh, Saudi Arabia.
b
Graduate student, Advanced Specialty Education Program in Prosthodontics, School of Dentistry, Loma Linda University School of Dentistry, Loma Linda, Calif.
c
Professor and Director, Advanced Specialty Education Program in Prosthodontics, Loma Linda University School of Dentistry, Loma Linda, Calif.
d
Assistant Professor, Advanced Specialty Education Program in Prosthodontics, School of Dentistry, Loma Linda University, Loma Linda, Calif.
e
Private practice, Austin, Texas.

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Figure 1. A, Intraoral frontal view showing fractured interim fixed complete denture. B, Occlusal view of maxillary arch showing preexisting implants. C,
Intraoral view of mandibular remaining natural dentition.

Figure 2. A, Intraoral frontal view of definitive wax trial prosthesis with maxillary milled titanium FCD framework. B, Casts view showing planned
prosthetic space for future mandibular anterior crowns before FCD processing. FCD, fixed complete denture.

After replacing the repaired interim FCD, various treat-
ment options were discussed. The decision was made to
fabricate a definitive FCD first to replace the interim
maxillary FCD and to restore the mandibular arch later to
accommodate financial constraints.34 To maintain OVD
and planned prosthetic space until the patient was ready
to proceed with the definitive treatment for the
mandibular arch without compromising restorative
outcome, a clear acrylic resin layer was added to the
definitive FCD opposing the mandibular teeth.
Stage 1
A maxillary implant level impression was made with
open tray impression copings and intraorally splinted
with light-polymerizing composite resin (Filtek Su-
preme Ultra Universal Restorative; 3M ESPE). Maxil-
lary and mandibular casts were poured in Type IV
dental stone (Resin Rock; Whip Mix Corp) with a
simulated soft tissue material (GI-Mask; Coltène)
around the maxillary implant analogs. An implant
screweretained flangeless maxillary occlusion rim was
fabricated to capture maxillomandibular relations at the
proposed OVD. After the definitive casts were moun-
ted, the teeth were arranged on the trial denture to
achieve mutually protected articulation. After intraoral
assessment of the trial maxillary FCD, a putty index
(Lab putty; Coltène) was generated from the wax
patterns.
An optical scanner (D900L; 3shape) was used to scan
the maxillary cast and trial tooth arrangement to design
and fabricate a milled titanium framework for the
maxillary FCD (NobelProcera; Nobel Biocare). The metal
framework at the trial placement was placed intraorally,
and a 1-screw test and radiographs were used to confirm
fit.35
The maxillary tooth arrangement was transferred to
the metal framework using the previously generated
putty index (Fig. 2), and the new wax trial prosthesis was
clinically evaluated. At this phase of treatment, the trial
maxillary FCD was placed, and the mandibular anterior
teeth were then restored with composite resin (Filtek
Supreme Ultra Universal Restorative; 3M ESPE)
(Fig. 3A). The OVD and the mandibular occlusal plane
were not changed. A new mandibular impression and
maxillomandibular relation records were made opposing
the trial maxillary FCD. The new mandibular cast was
duplicated (Capsil; Great Lakes Orthodontics). Both
duplicate casts were mounted on the same articulator
from the interocclusal records opposing the same trial
FCD. The FCD was processed in a conventional manner

THE JOURNAL OF PROSTHETIC DENTISTRY AlHelal et al

- 2017 3

Figure 3. A, Intraoral view of restored mandibular anterior teeth at interim treatment stage. B, Cast frontal view showing mandibular wax patterns
opposing processed definitive maxillary fixed complete denture. C, Cast view showing wax patterns of future mandibular anterior crown designed at
transitional treatment stage.

Figure 4. A, Cameo surface of maxillary processed FCD before modification. B, Occlusal view of modified FCD with clear acrylic resin as prosthetic space
maintainer. Interproximal acrylic resin was removed through to facial surface. Clear acrylic resin was added and contoured to create palatal anatomy to
blend with modified FCD. FCD, fixed complete denture.

in heat-polymerized acrylic resin (Lucitone 199; Dentsply
Sirona) (Fig. 3B). On one of the mandibular casts, a wax
pattern was made for the mandibular arch opposing
the processed FCD for the second stage of treatment
(Fig. 3B, C).
The other mandibular cast was attached to the
articulator at the same proposed OVD. Clear acrylic resin
(Jet Tooth Shade Powder; Lang Dental Manufacturing
Co) was injected onto the cameo surface of the maxillary
FCD palatal to the anterior teeth, and all excursive
mandibular movements were performed on the artic-
ulator to establish ideal occlusal contacts. Excess acrylic
resin was carefully removed from the palatal incisal
edges of the anterior teeth and the interproximal areas
to provide improved palatal form. The maxillary FCD
was then immersed in warm water (43 C) in a pres-
sure vessel at 200 kPa for 10 minutes to achieve
complete polymerization of the added resin (Fig. 4).
The FCD was then remounted, and the final finishing
and polishing were completed (Fig. 4B). The definitive
prosthesis was inserted intraorally (Fig. 5A). The fit of
the prosthesis, occlusion, esthetics, and phonetics were
reconfirmed, and occlusal screws were tightened
according to the manufacturer’s recommendations.
The screw access holes were sealed with composite
resin (Filtek Supreme Ultra Universal Restorative; 3M
ESPE). A mandibular acrylic resin interim removable
partial denture was placed to replace missing posterior
teeth.
Stage 2
After 12 months (Fig. 5B), the patient returned for
completion of treatment. The existing mandibular natural
teeth were prepared, and the clear acrylic resin was
removed from the FCD (Fig. 5C). Definitive impressions
for the mandibular arch were made for both prepared
teeth and uncovered implants. New maxillomandibular
relation records were made opposing the definitive FCD,
and the new mandibular definitive casts were mounted
on the same articulator. Mandibular interim restorations
were fabricated based on the previously made wax pat-
terns (Protemp Plus Temporization Material; 3M ESPE)
and cemented with interim cement (TempBond Tem-
porary Dental Cement; Kerr Corp).

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Figure 5. A, Intraoral frontal view of prosthetic space maintainer in occlusion, preventing supraeruption of opposing anterior teeth and providing
harmonious contact with all excursive mandibular movements without esthetic compromise. B, Occlusal view of maxillary modified fixed complete
denture at 12 months. C, Occlusal view after removal of clear acrylic at provisionalization stage of prepared mandibular anterior teeth.

Figure 6. A, Intraoral occlusal view of definitive mandibular prosthetic treatment. B, Intraoral frontal view of definitive complete-mouth rehabilitation.

Definitive milled zirconia (Multi-Layered Zirconia;
Talladium) restorations were fabricated for the mandib-
ular arch and cemented (Fig. 6A). The occlusion was
adjusted and polished as needed (Fig. 6B). Oral hygiene
instructions were given, and follow-up recall visits were
scheduled.
DISCUSSION
Complete-mouth rehabilitation is clinically challenging,
and the extensive nature of the treatment makes it unap-
pealing for patients on limited incomes.3-7 This clinical
report describes one such situation in which patient
expressed concerns regarding expenses associated with her
preferred treatment option. A staged approach was rec-
ommended to the patient to allow time for her to begin and
complete the second stage of treatment while addressing
her chief complaint immediately. Interim modification in
the form of clear acrylic resin was placed on the maxillary
FCD to maintain prosthetic space at the planned OVD and
the integrity of the remaining dentition. Using this staged
approach, the long-term outcome was not jeopardized
because of the delay in treatment completion. Further-
more, complications were avoided such as the need for
significant recontouring of the maxillary FCD, which could
have affected treatment outcome.9,24
The secondary adjunctive and interim approach hel-
ped maintain OVD, occlusal plane, and prosthetic space,
preventing the potential supraeruption of mandibular
anterior teeth and avoiding future need for excessive
tooth preparation, endodontic therapy, or crown-
lengthening surgery.9 Her OVD was restored and
maintained at the initial phase of treatment, which
served as a reversible and hence transitional prosthetic
modification. Interim phase modification to the FCD
could have been considered a definitive treatment if the
patient had not returned.
SUMMARY
A staged approach is described as an innovative way to
address long-term delay in complete- mouth rehabilita-
tion. Appropriate treatment planning and treatment
sequencing provided a predictable and successful clinical
outcome, even during the interim delayed phase of
treatment. The use of a substitutive treatment strategy
facilitated the transition from a single arch to the defin-
itive complete-mouth rehabilitation while effective space

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- 2017
maintenance prevented restorative complications during
the course of treatment.
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Corresponding author:
Dr Abdulaziz AlHelal
Loma Linda University
School of Dentistry
11092 Anderson St
Loma Linda, CA 92350
Email: alhelal.abdulaziz@gmail.com
Copyright © 2017 by the Editorial Council for The Journal of Prosthetic Dentistry.
THE JOURNAL OF PROSTHETIC DENTISTRY