Thông tin tài liệu
221
8
Complete Implant - Supported Restorations
Clinical Cases in Restorative & Reconstructive Dentistry, Gregory J. Tarantola, © 2010 Blackwell Publishing Ltd.
Case 1 Complete implant - supported maxillary reconstruction — transitioning the anterior teeth from
tooth - supported to implant - supported
Case 2 Complete maxillary nonremovable restoration supported by 6 implants converted from a
complete removable restoration on 4 implants
Case 3 Complete implant - supported nonremovable maxillary and mandibular reconstructions; transi-
tioning from natural teeth that were not predictably restorable
Case 4 Maxillary extractions, immediate implant placement, immediate loading, and complete nonre-
movable zirconia restoration with pink porcelain
Case 5 Mandibular implant bar – supported full removable denture converted to a nonremovable resto-
ration to improve comfort of the neutral zone and phonetics
222 Clinical Cases in Restorative & Reconstructive Dentistry
SUMMARY OF EXAMINATION AND DIAGNOSIS
Dentition
Endodontic and structural failure 6, 7, 10, 11
Guarded but maintainable condition of lower
anterior teeth
Posterior implants and restorations are accept-
able and do not need to be changed.
Periodontium
Stable
TMJ s
Right Piper 3B
Left Piper 3B
Both can be superiorly compressed with no sign
of tension or tenderness.
Muscles
Slight lateral and medial pterygoid palpation
discomfort
Occlusion
Interferences and slide when condyles are in
ACP
Aesthetics
Reverse smile of upper anteriors
Chapter 8 Case 1
Complete implant - supported maxillary reconstruction —
transitioning the anterior teeth from tooth - supported to
implant - supported
Today ’ s dentistry gives us the opportunity to transition
a failing tooth - supported restoration to an implant - sup-
ported solution. Patient circumstances often necessi-
tate a segmental approach rather than changing
everything at once. Before we make this decision, we
must evaluate thoroughly and verify that the form and
function of what will not be changed is acceptable or
can be made acceptable with equilibration and reshap-
ing alone.
This patient has had a posterior screw - retained
implant - supported restoration for many years. Although
a much better looking restoration could be done, the
one she had was acceptable to her, it was healthy,
THE 10 DECISIONS
1. TMJ Diagnosis
Treat to a guided adapted centric posture.
2. Vertical Dimension
Acceptable; maintain.
3. Lower Incisal Edge
Acceptable; just smooth and polish.
4. Upper Incisal Edge
Lengthen upper central incisors 1.5 – 2.0 mm.
5. Centric Stops
Defi nitive centric stops posteriorly with
equilibration
Defi nitive centric stops anteriorly with restoration
6. Anterior Guidance
Acceptable, it will steepen slightly with new
incisal edge position.
7. Curve of Spee
Acceptable
8. Curve of Wilson
Slight reverse Curve of Wilson. Correct as much
as possible with reshaping. It discludes com-
pletely even though not “ ideal looking. ”
9. Cusp/Fossa Angle
Acceptable
10. Aesthetic Plane
Improve reverse anterior smile line.
Posterior aesthetic plane is acceptable.
and it functioned well. The upper anterior teeth sup-
porting a fi xed restoration were hopeless and the plan
was to transition to an implant - supported restoration.
The lower anterior teeth supporting a fi xed restoration
have a guarded prognosis but will be maintained for as
long as possible. The functional landmarks were
acceptable, so there was no occlusal compromise.
CHAPTER 8 COMPLETE IMPLANT-SUPPORTED RESTORATIONS
Clinical Cases in Restorative & Reconstructive Dentistry 223
Figure 8.1.1. Preoperative panoramic. Upper anterior teeth
are hopeless. Lower anterior teeth guarded but maintainable
for the short term. Posterior implants and restorations
acceptable.
SUMMARY OF TREATMENT SEQUENCE
Appointment Treatment Completed
1 Surgeon to remove 6, 7, 10,
11
Immediate implant placement
Removable provisional
immediately placed
2 Time to heal and integrate
3 Equilibrate posterior teeth to
eliminate slide
Implant level impressions
4 Place custom abutments and
fi xed provisional.
Evaluate changes in form and
function.
5 Impressions of abutments
6 Place defi nitive restoration.
SUMMARY OF TREATMENT PLAN
Dentition
Remove 6, 7, 10, 11.
Immediate implant placement
Delayed restoration
Periodontium
Professional maintenance
TMJ s
No treatment is needed other than correct bite
engineering.
Muscles
No treatment is needed other than correct bite
engineering.
Occlusion
Equilibrate posteriorly; improve anterior guidance
with new restoration.
Aesthetics
Correct reverse smile of upper anterior, increase
length of centrals
Figure 8.1.2. Preoperative smile photograph, reverse smile
evident.
Figure 8.1.3. Preoperative retracted views.
224
Figure 8.1.4. Preoperative lingual views. Old but acceptable
screw - retained posterior implant - supported restorations. They
have been in place over 10 years.
Figure 8.1.5. Preoperative occlusal view.
Figure 8.1.6. Trial equilibrated articulated diagnostic casts. All
parameters of static and dynamic occlusion can be fulfi lled.
Maxillary anterior teeth will be lengthened.
Figure 8.1.7. Implant level impressions.
Figure 8.1.8. Custom abutments and soft tissue cast.
Implants are deep subgingivally. Custom abutment brings
restoration fi nish line to tissue level.
Figure 8.1.9. Putty index of verifi ed provisionals and
defi nitive restoration verifi ed.
Figure 8.1.10. Finished result, reverse smile improved.
CHAPTER 8 COMPLETE IMPLANT-SUPPORTED RESTORATIONS
Clinical Cases in Restorative & Reconstructive Dentistry 225
Figure 8.1.11. Posttreatment panoramic radiograph. Lower
anteriors still maintained as of 8 years posttreatment
completion of upper anterior.
CHAPTER 8 CASE 1 KEY POINTS
If the top of the implant is very deep, use a
two - piece or custom abutment to bring the
fi nish line of the restoration closer to the free
margin of the tissue.
Consider cemented restorations as the
treatment of choice over screw - retained
restorations.
226 Clinical Cases in Restorative & Reconstructive Dentistry
Chapter 8 Case 2
Complete maxillary nonremovable restoration supported by
6 implants converted from a completed removable
restoration on 4 implants
The patient in this case study had recently completed
a restoration from another dentist but she was not
pleased. She had expected a nonremovable restoration
but the defi nitive dentistry was a removable denture
supported by 4 implants. She had some very specifi c
ideas about the aesthetics she desired, so additional
time was spent before any treatment was initiated to
confi rm that her expectations could be met.
THE 10 DECISIONS
1. TMJ Diagnosis
Treat to a guided, verifi able adapted centric
posture.
2. Vertical Dimension
Determined by traditional denture techniques
with 2 mm of freeway space
3. Lower Incisal Edge
Acceptable; just smooth and polish.
4. Upper Incisal Edge
Current restoration is acceptable.
5. Centric Stops
Simultaneous, equal intensity centric stops in the
adapted centric posture arc of closure
6. Anterior Guidance
Determined by fi nalized upper and lower incisal
edge position
7. Curve of Spee
Lower needs minor reshaping to improve.
8. Curve of Wilson
Lower needs minor reshaping to improve.
9. Cusp/Fossa Angle
Shallower than the anterior guidance disclusive
angle
10. Aesthetic Plane
Create an upper posterior aesthetic plane that is
consistent with the upper incisal edge position
and with pleasing buccal profi les.
SUMMARY OF EXAMINATION AND DIAGNOSIS
Dentition
4 upper implants, unacceptable denture
Lower teeth have many restorations, recently
completed orthodontics.
Periodontium
Lower is guarded to hopeless.
TMJ s
Right side Piper 2
Left side Piper 2
Both can be superiorly compressed comfortably.
Muscles
Lateral pterygoids uncomfortable to palpation
Occlusion
Lower functional landmarks are acceptable or
easily modifi able.
Aesthetics
Incisal edge position is acceptable but size,
proportion, and color are not.
CHAPTER 8 COMPLETE IMPLANT-SUPPORTED RESTORATIONS
Clinical Cases in Restorative & Reconstructive Dentistry 227
SUMMARY OF TREATMENT SEQUENCE
Appointment Treatment Completed
1 Removable provisional to be
used as a diagnostic wax - up to
verify that expectations can be
met
2 Once (and if) approved, place
2 more posterior implants.
3 Heal and integrate.
4 Implant level impressions for
custom abutments
5 Place abutments and retrofi t
previously approved
provisional.
6 Evaluate and modify
provisional.
7 Defi nitive impression and bite
records
8 Place upper defi nitive
restoration.
9 Plan lower when appropriate.
SUMMARY OF TREATMENT PLAN
Dentition
Place 2 more implants.
Nonremovable implant - supported restoration
Periodontium
Maintain lower by periodontist until patient is
able to proceed with an implant solution.
TMJ s
No treatment is needed other than to correct
occlusal engineering.
Muscles
No treatment is needed other than correct
occlusal engineering.
Occlusion
Simultaneous equal intensity contacts in centric
relation and anterior guidance on anterior teeth
Aesthetics
Idealize form, contour, and proportions. Gingiva
will be simulated with pink porcelain.
Figure 8.2.1. Pretreatment anterior and lateral smile
photographs. Restoration is a removable complete implant -
retained denture. She desires a nonremovable solution.
Incisal edge position is acceptable but she feels teeth are
too large. A nonacrylic denture material was used (Valplast)
because of a suspected acrylic allergy.
Figure 8.2.2. Pretreatment anterior and lateral retracted
photographs. The denture fl ange was shortened because of
path of insertion problems due to facially angulated anterior
implant placement. Orthodontics was completed on the
mandibular resulting in acceptable functional landmarks. This
will allow upper dentistry to be completed without treating
lower at this point. Patient circumstances necessitated lower
treatment being delayed.
228
Figure 8.2.3. Pretreatment maxillary occlusal photographs.
The two most posterior implants have Locator abutments for
denture retention. The two most anterior implants have
healing caps because severe angulation prevented their use
as an abutment. Several other teeth were recently extracted.
Figure 8.2.4. Pretreatment panoramic radiograph illustrating
major periodontal issues with the mandibular teeth. Patient is
fully aware of the diagnosis.
Figure 8.2.6. Lateral smile photographs of the provisional in
Figure 8.2.5 . Lip support was acceptable, verifying that a
denture fl ange is not necessary and that a nonremovable
approach is possible.
Figure 8.2.7. Anterior and lateral retracted photographs of
the provisional in Figure 8.2.5 . It simply sets on the current
abutment situation for diagnostic evaluation.
Figure 8.2.8. Anterior and lateral smile photographs of a
second attempt at a diagnostic provisional. Patient
comments about fi rst diagnostic provisional were
incorporated into this second attempt. The teeth were made
narrower mesiodistally, and pink acrylic to simulate gingival
was used to make the teeth appear smaller incisogingivally.
This fulfi lled her aesthetic expectations.
Figure 8.2.5. Photographs of a diagnostic provisional made
on the initial articulated diagnostic casts. This is not attached
to the implants but sets on the current abutments and is
stable and retentive enough for evaluation. Although incisal
edge position was acceptable, the patient did not like the
width and incisal - gingival length of the teeth.
229
Figure 8.2.9. Anterior and lateral retracted photographs of
the second diagnostic provisional. Current mesiodistal
implant position aligned favorably with the maxillary lateral
incisors. The pink acrylic fi ts to the edentulous ridge like a
pontic; there is not a denture fl ange. Since this was
acceptable to the patient, the plan of a nonremovable
restoration was indeed possible and would achieve
acceptable results. Two more posterior implants were
needed for the support necessary to make a nonremovable
restoration. All this was done prior to making any irreversible
changes to the patient. She simply continued to wear her
current removable prosthesis. It was extra work but well
worth the effort in gaining assurance that patient
expectations could be met.
Figure 8.2.11. Lateral smile photograph of the second
provisional confi rming acceptable lip support.
Figure 8.2.10. Maxillary occlusal photograph after placement
of two more implants and fi nalized abutments. The two
anterior abutments are 8 mm solid healing abutments
prepped and used as fi nal abutments. A two - piece abutment
could not be used because the screw head would have been
totally obliterated to gain a path of insertion in the facially
inclined implants. This creative solution allowed these
implants to be used as abutments.
Figure 8.2.12. Anterior and lateral retracted photographs of
the cemented nonremovable provisional. The second
diagnostic provisional was used as a defi nitive fi xed
provisional over the fi nal abutments.
Figure 8.2.13. Anterior and lateral smile photographs of the
defi nitive restoration using pink porcelain to simulate the
gingival. Note similarities with the provisional restoration.
PART 2 CASE STUDIES
230 Clinical Cases in Restorative & Reconstructive Dentistry
Figure 8.2.14. Anterior and lateral retracted photographs of
the cemented defi nitive restoration. The second molars are
cantilevers. The entire restoration is supported by the six
implants. The patient was pleased with the fi nal result and
very happy to have a nonremovable restoration — her primary
desire and expectation.
CHAPTER 8 CASE 2 KEY POINTS
In totally edentulous cases, a nonremovable
restoration is possible if a fl ange is not
needed for lip support.
Time spent at the diagnostic phase making
even multiple “ preview ” restorations is never
wasted time.
Even if the opposing arch may not be treated
right away, make needed functional or land-
mark changes with reshaping and composite
additions as needed.
[...]... relationship Interferences to maximum intercuspation in the centric arc of closure Anterior teeth couple in maximum intercuspation but not after trial equilibration, indicating a significant horizontal component to the condylar shift form maximum intercuspation to adapted centric posture Aesthetics Excessive maxillary incisal edge and gingival display Retrusive jaw and chin 256 Clinical Cases in Restorative & Reconstructive. .. mandibular restorations The slight marginal gap on the maxillary left last abutment was deemed to be clinically acceptable 236 Clinical Cases in Restorative & Reconstructive Dentistry Chapter 8 Case 4 Maxillary extractions, immediate implant placement, immediate loading, and complete nonremovable zirconia restoration with pink porcelain The patient in this case study has a failing maxillary and mandibular reconstruction... Retruded mandible and chin 250 Clinical Cases in Restorative & Reconstructive Dentistry THE 10 DECISIONS 1 TMJ Diagnosis Begin bite splint therapy in a treatment position with the goal of adapted centric posture 2 Vertical Dimension Open with orthodontics as occlusal plane is leveled 3 Lower Incisal Edge Move down and forward with orthodontics and orthognathics 4 Upper Incisal Edge Move lingually with orthodontics... current implant position Clinical Cases in Restorative & Reconstructive Dentistry 243 9 Orthognathics Case 1 Severe anterior open bite corrected with maxillary-only orthognathics and occlusal therapy with upper incisor restorations Case 2 Mandibular orthognathic surgery and chin implant; managing a temporomandibular disorder during treatment; posterior restorative dentistry including implants Case 3 Maxillary... main concern for seeking treatment—it may not be what we initially assume it to be Figure 9.1.7 Provisionals followed by crowns 7–10 The crowns were splinted to act as an orthodontic retainer Figure 9.1.8 Twelve years posttreatment Occlusion does need to be refined yearly, as expected, based on TMJ diagnosis Relatively stable considering the condition of his condyles Clinical Cases in Restorative & Reconstructive. .. main motivator There are significant condylar changes but no signs or symptoms The main issue is to determine stability, which will help us make a prognosis of occlusal stability This will be accomplished with a bite splint Then we can proceed with orthodontics, orthognathics, and definitive occlusal /restorative treatment 246 Clinical Cases in Restorative & Reconstructive Dentistry SUMMARY OF EXAMINATION... patient was counseled regarding the potentially weak nature of longstanding endodontics with large posts A chin implant and advancement was also done Clinical Cases in Restorative & Reconstructive Dentistry 255 Chapter 9 Case 3 Maxillary and mandibular orthognathic surgery with chin advancement; prerestorative occlusal therapy with equilibration and composite additions The patient in this case study wanted... engineering evaluation and refinement Clinical Cases in Restorative & Reconstructive Dentistry 247 Figure 9.1.1 Preoperative smile and retracted view Despite the open bite, he is quite happy with his smile Figure 9.1.4 Bite splint in full occlusal contact worn for 4 months to assess stability Occlusion changed very little, if at all, suggesting TMJ stability Orthodontics was started after the bite splint... Verify that upper buccal and lower lingual cusps do not interfere in the functional and parafunctional range of motion 9 Cusp/Fossa Angle Shallower than the anterior guidance disclusion angle 10 Aesthetic Plane Create an upper posterior aesthetic plane that is consistent with the upper incisal edge position and with pleasing buccal profiles Clinical Cases in Restorative & Reconstructive Dentistry 231 PART... surgery with chin advancement; prerestorative occlusal therapy with equilibration and composite additions See also: Chapter 16 Case 1 Severe anterior overjet handled with occlusal /restorative treatment in lieu of orthognathics; muscular component of a temporomandibular disorder also managed Clinical Cases in Restorative & Reconstructive Dentistry, Gregory J Tarantola, © 2010 Blackwell Publishing Ltd 245 . the upper incisal edge position
and with pleasing buccal profi les.
PART 2 CASE STUDIES
23 2 Clinical Cases in Restorative & Reconstructive Dentistry
. of the neutral zone and phonetics
22 2 Clinical Cases in Restorative & Reconstructive Dentistry
SUMMARY OF EXAMINATION AND DIAGNOSIS
Dentition
Ngày đăng: 06/03/2014, 12:21
Xem thêm: Clinical Cases in Restorative & Reconstructive Dentistry_2 potx, Clinical Cases in Restorative & Reconstructive Dentistry_2 potx