Complete Transformation of a Failing Dentition

Today, more and more patients are presenting to dental practices in need of some form of reconstruction of the teeth, gums, and jaw, or any combination of these in an otherwise normal mouth. The need for reconstructive dentistry, sometimes the result of an accident or heredity, is frequently the result of poor oral hygiene or neglect. It is often desired for aesthetic reasons, but can be medically necessary if the problem interferes with the normal functions of the mouth. Sometimes, chewing or speech is hindered as the result of decay, periodontal disease, or injury. Multiple missing teeth, temporomandibular joint disorders, and other medical problems may also require that reconstructive dentistry be done. Reconstructive dentistry may involve the construction of new teeth with crowns and bridges utilizing a variety of materials including, but not limited to, composite resins and/or all-ceramics. In addition, it may include the placement of dental implants to support fixed dental bridges or snap-on overdentures.

CASE REPORT
Diagnosis and Treatment Planning
A patient in her mid-40s presented, wanting to enhance her smile (Figures 1 and 2). She was referred to me from her existing dental provider who was frustrated over how to restore her dentition due to her overgrown maxilla, malocclusion, and gummy smile.

Figure 1. Pre-op full-face view.

Figure 2. Pre-op retracted view.	Figure 3. Pre-op panoramic (Panorex) radiograph.

Initial diagnostic evaluation consisted of a series of digital images with study casts, a bite registration, and radiographs (Figure 3). The patient had some existing crown restorations (with posts and cores) on teeth Nos. 7 to 12 that had recurrent decay as well as periapical lesions that would spontaneously flare up. In her upper right quadrant, tooth No. 1 had gross decay in addition to tooth No. 3, which also exhibited hyper-eruption since there was no opposing tooth present in the No. 30 area. In her upper left quadrant, there was a failing bridge (teeth Nos. 13 to 15) with gross decay at the margins. After periodontal probing and a review of her full-mouth radiographs, it was apparent the patient suffered from localized periodontal disease and decay in the maxillary arch. Additionally, it appeared that an untreated developmental occlusal and skeletal problem actually caused the patient’s upper anterior arch of teeth to drop down with excessive bone growth. The patient also exhibited a deep bite, with the upper teeth closing down near the free gingival margin of the lower teeth. A prior attempt to correct these conditions with crowns several years earlier by another clinician was unsuccessful. The mandibular arch also had an edentulous area (Nos. 30 and 31); otherwise, the lower arch was within normal limits.

For the purpose of developing a treatment plan, diagnostic models were forwarded to the dental lab team to be mounted on a semi-adjustable articulator (Denar Combi II Articulator [Whip Mix]) for further analysis in order to best meet the patient’s aesthetic and functional needs. Instructions for a diagnostic wax-up were prescribed for apically positioning the anterior teeth to a more ideal position, while maintaining her vertical dimension of occlusion.

As a result of the information gathered from the diagnostic wax-up, it was obvious that aesthetics and function would be enhanced by restoring the entire maxillary arch. Once all risks, benefits, and alternatives of various treatment options were reviewed with the patient, it was decided that the final treatment plan would consist of extracting the entire maxillary dentition followed by reducing and reshaping the maxilla for optimal aesthetics. In doing so, the patient would no longer have excessive bone and gum visible in the aesthetic zone. Once healed, dental implants would be placed utilizing CT-based guided surgery to support a fixed partial denture (FPD) from teeth Nos. 2 to 15.

First Surgical Appointment
In full-mouth extractions cases such as this, I will utilize intravenous sedation to make the procedure more efficient. Not only does it make the appointment easier for me; patients prefer to get as much treatment done in one visit as possible, often due to fear. Since they are sedated, a mouth prop (such as Logibloc [Common Sense Dental Products]), is used to keep the mouth open (Figure 4). Logibloc’s unique design comfortably supports and stabilizes the jaw, while allowing the dental provider unrestricted visual and physical access to the working area.

Figure 4. Reflection of periodontal flap.	Figure 5. Extractions were done using the Physics Forceps (Golden Dental Solutions).
Figure 6. Placement of bone grafting material (Maxxeus).	Figure 7. Immediate soft reline (UFI Gel [VOCO America]) after suturing.

Figure 8. Full-face view of immediate denture.

In order to extract a full arch of teeth efficiently, without breaking or disturbing the bony substructure, I used the Physics Forceps (Golden Dental Solutions) (Figure 5). The Physics Forceps act like a modified Class I lever. The beak of the forceps was placed on the lingual cervical portion of the tooth, where the soft bumper portion was placed on the buccal alveolar ridge at the approximate location of the muco-gingival junction. During the extraction process, the beak grasps the tooth and the bumper acts as the fulcrum. Extractions were accomplished with only wrist action in a buccal direction taking about 30 to 60 seconds each, depending on the tooth morphology.

Once all the maxillary teeth were extracted, the alveolar crest was leveled 3 to 4 mm apically with the AEU-7000 surgical motor/handpiece (Aseptico), so that the patient’s maxilla would not be visible during smiling. By eliminating the potential for visibility of the transition between the prosthesis and the soft tissue of the maxillary ridge, the aesthetic prosthetic result was maximized.¹

A putty blend of cortical mineralized and demineralized bone grafting material (Maxxeus) was placed in the sockets to further enhance preservation of the ridge (Figure 6). This combination leverages the complementary benefits of space-maintaining mineralized bone with osteoinductive demineralized matrix to optimize the environment for the regeneration of vital bone.² Primary closure was achieved by suturing the tissue with 3.0 mm sutures (Black Silk Sutures [Blue Sky Bio]).

Following the extractions, leveling, grafting, and sutures, a soft reline material (UFI Gel Soft Reline [VOCO America]) was selected to reline the maxillary denture (Figure 7). Composed of a vinyl polysiloxane (VPS), it only required application of a bonding agent to the immediate denture to ensure adhesion of the soft liner to the hard acrylic denture base. However, before applying adhesive to the internal aspect of the immediate upper denture, one should always verify that there are no undercuts.

Three days postoperatively, the patient returned with some slight swelling, but no discomfort was reported. She was very pleased with her new enhanced smile already achieved with the immediate upper denture (Figure 8). The next step in her treatment would consist of guided dental implant placement and restoration in 4 to 6 months.

Second Surgical Appointment
Before the second surgical appointment, a CBCT scan (i-CAT [Imaging Sciences International]) was taken to accurately treatment plan this case. The final treatment plan would consist of a fixed bridge on implants in the upper arch. SimPlant software (Materialise Dental) was used through 3D Diagnostix virtual assistance to precisely plan the placement of 9 dental implants—7 Engage (OCO Biomedical) and 2 Macro (OCO Biomedical)—in the maxillary arch using a CT-based surgical pilot guide (Figure 9). In the posterior maxillary region, sinus augmentation would be performed through the osteotomies for the most distal implants using the DD-Sinus Lift Kit (OCO Biomedical) and a blend of cortical mineralized and demineralized bone grafting material (Maxxeus).

Figure 9. Virtual Planning (3D Diagnostix).	Figure 10. Aseptico surgical motor.
Figure 11. 3D Diagnostix surgical guide kit.	Figure 12. Virtual plan of sinus bump.
Figure 13. Utilization of DD-Sinus Lift Kit (OCO Biomedical).	Figure 14. Macro implant (OCO Biomedical).
Figure 15. Panoramic radiograph of implants placed.	Figure 16. Osseointegrated implants at 4 months after placement.

With the combination of their patented Bull Nose Auger tip and Mini Cortic-O Thread, the OCO Biomedical implant line was utilized due to its high initial stability for selective loading options. Other dental implant systems with aggressive threading may include but are not limited to: Nobel Active (Nobel Biocare), Seven (MIS Implants Technologies), ETIII (HIOSSEN), I5 (AB Dental USA), Conus 12 (Blue Sky Bio), and Any Ridge (Mega’Gen USA).

Once the patient was anesthetized, a tissue-borne, CT-based pilot surgical guide provided by 3D Diagnostix was inserted and stabilized with 2 retention pins to the maxillary arch. Using the Mont Blanc surgical handpiece and Aseptico surgical motor (AEU-7000) at a speed of 1,200 rpm with copious amounts of chilled sterile saline (Figure 10), the sites for the implants were initiated with a 1.95 mm pilot drill provided in the 3D Diagnostix Guided Surgical Kit (Figure 11).

Next, to confirm the accuracy of the surgical guide, paralleling pins were placed in the sites of the osteotomies. Radiographs were then taken to check the angulations of the pins within the maxilla. Once confirmed, a rotary tissue punch was used to remove a circular portion of gum tissue in the crest of the ridge that corresponded with the diameter of the implant.

Instead of using multiple downward cutting twist drills to prepare an osteotomy, the OCO Biomedical line employs an irrigated tri-flute, side cutting “osteotomy former” to shape the final osteotomy. This enables the implant to have maximal bone to thread fixation at placement.3 Most importantly, the non-end cutting tip will drill no deeper than the pilot drill. In the posterior maxillary areas where additional height was needed, the DD-Sinus Lift Kit was used to elevate the sinus followed by grafting material before implant placement (Figures 12 to 14).

Once the osteotomies were complete, an implant driver was used to place the dental implants until increased torque was necessary. The ratchet wrench was then connected to the adapter and the implants torqued to final depths reaching a torque level of about 45 to 50 Ncm. Adequate implant fixation was further verified using an Osstell ISQ implant stability meter (Osstell USA) which uses resonance frequency analysis (RFA) as a method of measurement. Several studies have been conducted based on RFA measurements and the implant stability quotient (ISQ) scale. They provide valid indications that the acceptable stability range lies above 55 to 60 ISQ.

Next, extended healing caps were hand-tightened to the implants and, to ensure complete seating, a postoperative radiograph was taken of the implants and healing caps (Figure 15). The immediate dentures were then relieved in the areas of the implants with AEU-12C1 Torque Plus lab motor/handpiece (Aseptico) and soft relined (Ufi Gel Soft).

The immediate dentures were actually more retentive by using the extended healing caps with the soft reline. After one week, the soft tissue and implants were evaluated, and the patient stated that she had very minimal postoperative discomfort and/or swelling.

Prosthetic Phase
Approximately 16 weeks after implant placement, the patient returned for the prosthetic phase of her treatment. The gingival tissue around the implants was very healthy, so the healing caps were removed and the implants evaluated (Figure 16). Each implant was tested with the Osstell ISQ implant stability meter (Figure 17). Implant stability was measured by using the instrument together with the wireless Smart Peg attached to an implant. There are implant-specific Smart Pegs available for a variety of dental implants. Most importantly, the technique is totally noninvasive with patients experiencing no sensation from the measurement, which takes one to 2 seconds. Implant stability is displayed as an ISQ value by the instrument. This ISQ value is derived from the resonance frequency of the peg, which in turn depends on the stability of the implant.⁴ All 9 implants tested with ISQ values higher than 73, meaning there was very good osseointegration.

Figure 17. Osstell reading was very good.	Figure 18. Impression posts placed.
Figure 19. Thermoplastic tray (Instant Custom C&B Trays [Goodfit]) was loaded with a vinyl polysiloxane impression material (Take 1 Advanced [Kerr]).	Figure 20. Impression was taken using the thermoplastic tray.
Figure 21. Lab-trimmed abutments.	Figure 22. Occlusal view of provisional restoration.
Figure 23. Occlusal view of PFM restoration.	Figure 24. Post-op retracted view of final restoration.

Since all the dental implants were well integrated, impressions were taken for the abutments, temporaries, and final restorations. Using impression posts (Figure 18), full-arch impressions were taken using Instant Custom C&B Trays (Goodfit). These custom trays can be fitted/adapted in just a few minutes, obviating the need for models, light-cure materials, monomers, and additional laboratory time for custom impression tray fabrication; this is because they are made of a material (polymethyl methacrylate) that is adjustable when heated and then maintains its shape once cooled.

After the trays were shaped properly for the patient, full-arch impressions were taken using a VPS impression material (Take 1 Advanced [Kerr]) (Figures 19 and 20). Bite relations, as well as instructions for size, shape, and color for a full-arch provisional, were forwarded to our dental laboratory team.

Within 3 weeks, the custom abutments and full-arch provisional were sent to our office. Utilizing an insertion jig, the abutments were screwed into their corresponding implant (Figure 21). The full-arch provisional was then cemented with a resin-based temporary cement (Temp-Bond Clear [Kerr]) (Figure 22). Aesthetics, phonetics, and bite of the provisional were evaluated and documented. The patient was very pleased with the aesthetics and function of this provisional restoration. She was instructed about its care and use in eating, speaking, and biting.

Figure 25. Panoramic radiograph of the seated fixed partial denture.

At the next appointment, the full-arch provisional restoration was removed using the Pneumatic Crown and Bridge Remover (Dent Corp). Any residual temporary cement was removed and the abutments were then inspected. If there was any further settling or recession of the gingival tissue, the abutments were modified using a carbide bur. This was done using copious amounts of water to avoid overheating any of the abutments. In this way, the margins could be brought right to, or slightly below, the free gingival margin. Next, a full-arch VPS impression was taken as was done for the abutments and the provisionals using the heat moldable Custom C&B Tray. Bite relations were also taken.

Within 3 weeks, the full-arch PFM restoration was tried-in and radiographs were taken to ensure complete seating. Once confirmed, the FPD restoration was cemented with a noneugenol resin cement (Premier Implant Cement [Premier Dental Products]) and allowed to set (Figures 23 and 24). Premier Implant Cement is a unique cement with a 2-stage cure that makes seating the restoration and removing excess cement very easy. In addition, its rigid final set and low solubility in oral fluids provide marginal seal and excellent retention.⁵

Once the restoration was cemented and cleaned, a panoramic (Panorex) radiograph was taken (Figure 25).

The patient was very pleased with the overall result and commented on how much more confident she felt with her new and enhanced smile (Figure 26).

Figure 26. Post-op photo of our very happy patient.

CLOSING COMMENTS
More and more patients are presenting to dental practices requiring some type of dental reconstruction. Having the access to advanced technology and materials within the practice allows the clinician to address a variety of different challenges efficiently and effectively. An important key to this process is to understand the aesthetic desires and functional needs of the patient. By following certain guidelines in smile analysis, CBCT planning, surgical protocol, and material selection, the dental provider can nearly always handle any restorative challenge while meeting or exceeding patient expectations.

References

1. Maló P, Rangert B, Nobre M. All-on-4 immediate-function concept with Brånemark System implants for completely edentulous maxillae: a 1-year retrospective clinical study. Clin Implant Dent Relat Res. 2005;7(suppl 1):S88-S94.
2. Holtzclaw D. Extraction site preservation using new graft material that combines mineralized and demineralized allograft bone: a case series report with histology. Compend Contin Educ Dent. 2014;35:107-112.
3. OCO Biomedical. Engage dental implants product information Web page. ocobiomedical.com/products/dental-implants/engage. Accessed on September 9, 2014.
4. Rodrigo D, Aracil L, Martin C, et al. Diagnosis of implant stability and its impact on implant survival: a prospective case series study. Clin Oral Implants Res. 2010;21:255-261.
5. Gultekin P, Gultekin BA, Aydin M, et al. Cement selection for implant-supported crowns fabricated with different luting space settings. J Prosthodont. 2013;22:112-119.

Dr. Nazarian maintains a private practice in Troy, Mich, with an emphasis on comprehensive and restorative care. He is a Diplomate in the International Congress of Oral Implantologists and is the director of the Reconstructive Dentistry Institute. He is also the creator of the DemoDent patient education model system. His articles have been published in many of today’s popular dental publications, and he has conducted lectures and hands-on workshops on aesthetic materials and dental implants throughout the United States, Europe, New Zealand, and Australia. He can be reached at (248) 457-0500 or via the Web site aranazariandds.com.

Disclosure: Dr. Nazarian reports no disclosures.