Full-Mouth Rehabilitation: A Case Study

INTRODUCTION
Our society has become one of impatience in the quest for immediate satisfaction. In 2012, The Huffington Post’s Pam Skoff¹ said, “We can look up any question we have, (and) fact check the person you are having a conversation with on the Internet via smartphones, instantly. Having this capability has made us instant-gratification junkies.” The patients in our practices are no different, in that they are a reflection of the world that surrounds them. The direct effect on the dental profession has been a paradigm shift in dental implantology that has driven the need for immediate load and immediate restoration; it has driven the concept of “teeth in a day.” These same patients are no longer satisfied with a removable temporary prosthesis and are demanding a fixed alternative in order to live their lives with a minimal amount of discomfort and inconvenience.

When a patient is faced with a hopeless dental condition, it is our job as dental professionals to provide not only long-term oral healthcare, but to also help the patient in an expedient manner with the least amount of psychological trauma. I mention psychological trauma because that is exactly what happens when an individual, who may otherwise be healthy, is faced with losing all one’s teeth. Becoming edentulous at any age becomes a significant turning point for these individuals. It is the time in their life when they can go from feeling young and vital to old and embarrassed, and even ashamed.

The following case will serve to demonstrate how dental practitioners can change patients’ lives by rehabilitating them with the combination of immediate-load implant technology and outstanding restorative materials.

CASE REPORT
Diagnosis and Treatment Planning
A 51-year-old male was diagnosed with failing dental health due to chronic periodontal disease. He had an unremarkable medical history, without any apparent systemic pathology that contributed to his dental condition. The patient admitted to “not always brushing,” but had come to understand the ramifications of poor oral hygiene too late. His maxillary posterior teeth presented with Class III mobility and were symptomatic. For the last 5 years, he had been delaying treatment and collecting estimates from various clinicians in his geographical area. A combination of fear and finances had kept him from proceeding with the treatment that he required.

Upon examination in our clinic, the following 2 potential treatment options were offered to him:

1. Extraction of all hopeless teeth combined with aggressive periodontal therapy for those anterior teeth that could be saved. Implant placement would be treatment planned in all the soon-to-be edentulous areas.

2. Full-mouth edentulation with immediate temporization and subsequent delivery of a definitive fixed dental prosthesis. Maxillary implant-supported fixed bridge and mandibular hybrid fixed/removable overdenture would be treatment planned.

Figure 1. Pre-op panoramic radiograph (Panorex).	Figure 2. Pre-op intraoral condition.

Figure 3. CBCT planning (PreXion).

The preoperative panoramic radiograph (Figure 1) and photos (Figure 2) showed that the patient was suffering from advanced periodontal disease that had severely compromised his dental health. After extensive discussion, the patient chose the plan that included full-mouth edentulation with subsequent full-arch restorations. The maxillary implants were treatment planned using CBCT and planning software (PreXion) (Figure 3).

Synopsis of Clinical Treatment
The treatment was carried out in 2 phases. The lower arch was edentulated along with the maxillary posterior (teeth Nos. 1 to 3 and Nos. 14 and 15). Six OCO Biomedical Engage implants were placed in the mandible. A temporary screw-retained overdenture was fabricated and delivered at the time of mandibular edentulation. The arch was then definitively restored with a removable-fixed hybrid restoration on the 6 implants. The patient chose to go without a temporary posterior restoration during the healing phase. He also declined bilateral sinus elevation surgery to increase vertical bone height in the posterior to facilitate implant placement.

This article will now concentrate on the second phase of treatment, specifically the maxillary arch and its surgical and restorative protocol.

Clinical and Restorative Protocol: Second Phase of Treatment
After profound anesthesia was established in the maxillary arch with 4% Septocaine (Septodont), teeth Nos. 5 to 12 were atraumatically extracted using conventional elevators and forceps (Figure 4). The key to facilitating immediate implant therapy is the ability to preserve as much native bone as possible, done to minimize the hard- and soft-tissue changes that can result from the removal of teeth. The potential sequelae is that “horizontal bone loss of 29% to 63%, and vertical bone loss of 11% to 22% can occur after 6 months following tooth extraction.”² A careful and atraumatic approach is extremely important in order to get not only the aesthetic results that the patient desires, but to preserve soft-tissue architecture (to avoid the potential for food impaction sites).

Once all the remaining teeth were extracted, alveoloplasty was performed to even out any atypical bony architecture (Figure 5) that resulted from the periodontal condition with which the patient presented.

All extraction sites were then debrided of any granulation tissue with a small, serrated curette (Zoll Dental). Initial trajectory was established with a 1.8-mm pilot bur and the final osteotomies were completed with 4-mm upper osteotomy formers (Figures 6 and 7). An Aseptico AEU-7000 motor at a drilling speed of 1,200 rpm was used to drive the surgical instrumentation. The OCO Biomedical surgical protocol is very expedient and simple. This is because it utilizes a unique step-drill design (Figure 8) in the final osteotomy former, alleviating the need for the usual serial progression of the osteotomy drills that is so common with most implant placement protocols. The final dimensions of the osteotomies were completed with one additional drill after the pilot hole established depth and trajectory.

Figure 4. Maxillary arch after extraction.	Figure 5. Alveoloplasty completed.
Figure 6. Pilot drill.	Figure 7. Final osteotomy former.
Figure 8. Osteotomy former with step-drill design.	Figure 9. Esthetic Region Implant (OCO Biomedical).
Figure 10. Delivering implant on carrier (Ultem [Sabic Global]).	Figure 11. Implants in place.

Once the final osteotomies were completed, the integrity of all sites was checked by sounding 360° around the osteotomy with a periodontal probe. OCO Biomedical Esthetic Region Implants (ERIs) were utilized for this case. The ERI has a 1.0-mm titanium nitride coated embedded-tapered platform (Figure 9). This design is ideal for areas with thin gingival biotypes and immediate implant placement. Couple this with an aggressive thread design that provides outstanding primary stability, and one has the perfect combination for immediate implant placement. For this case, four 4.0 x 12 mm ERI implants were placed in site Nos. 7 to 10. The implants were delivered by hand using the attached Ultem carrier (Sabic Global) (Figure 10), with the restorative platform at the facial crest level (Figure 11). The implants for site Nos. 4 and 12 were 4.0 x 14 ERIs angled distally to avoid the maxillary sinuses bilaterally. All implants were fully seated, then torqued into place with a calibrated torque wrench. An average of 45 Ncm was achieved for all 6 implants. An average implant stability quotient (ISQ) of 71 was recorded for all implants using an Osstell meter. Taking into account both the insertion torque value and the ISQ reading, excellent primary stability was verified. The criteria for direct loading was insertion torque of 30 Ncm and an ISQ > 60 on the most posterior implants and a sum of 200 ISQ (average 50 ISQ) on the 4 anterior implants.³

Any gaps between implants and the existing sockets were grafted with DBM putty (MS Biologics). In cases like this, the combination of immediate placement, grafting, and immediate temporization give the best potential outcome.⁴

Offset-15° shielded abutments (OCO Biomedical) were used as temporary abutments facilitating a common path of withdrawal to support an immediate complete arch (fixed) temporary (Figure 12). Under copious water spray, minor adjustments were made to the titanium abutments using a high-speed handpiece and a coarse, football-shaped diamond (Figure 13). A preoperative diagnostic model was used to create a plastic suck-down matrix that was filled with acrylic composite temporary material (Visalys Temp [Kettenbach LP]) (Figure 14). Once cured, the temporary material was trimmed, and proper emergence profiles, along with embrasure spaces, were created to facilitate the preservation of the interdental papilla. The combination of very high initial stability, coupled with cross-arch stabilization, allowed for a predictable and strong immediate fixed temporary which distributed even loads to all the implants in the arch. By not having to use a removable temporary prosthesis, higher patient satisfaction can be achieved and a more predictable and aesthetic soft-tissue architecture can be accomplished.

Once the temporary was completed, the soft tissue (which had been sutured with 3.0 chromic gut [Ethicon]) was recontoured for optimal aesthetics. The temporary prosthesis was then cemented with IRM (DENTSPLY Caulk), the occlusion checked, excess cement removed, and the patient dismissed (Figure 15). Oral hygiene instructions were explained, and no dietary restrictions were given. The patient returned to work the next day.

Routine postoperative examinations were completed at one week, 4 weeks, and at 3 months. During this time, both the hard and soft tissues healed predictably (Figure 16) and there were no prosthetic complications that affected treatment. Though the definitive restoration could have been fabricated at an earlier point in the treatment, complete integration and soft-tissue healing was allowed to avoid any potential complications.

Final impressions were taken at the fixture level with a combination of closed- and open-tray impression copings using a vinyl polysiloxane impression material (Identium [Kettenbach LP]). The temporary restoration helped create and maintain the proper papillary form necessary to alleviate the potential of outcome of “black triangles” between restorations (Figure 17). Again, utilizing stock, offset shielded abutments (Figure 18) to keep restorative costs down, the dental lab (Cosmetic Arts, Albuquerque, NM) modified the abutments and created a CrCo framework for try-in (Figure 19). We have had great success utilizing CrCo frameworks to provide an alternative to costly gold-based restorations. After verification of fit visually, tactically, and by radiograph, a bite registration and jaw record were completed to facilitate precise articulator mounting. The case was then sent back to the lab for the stacking of porcelain and completion.

Figure 12. Shielded abutments (Offset-15° [OCO Biomedical]).	Figure 13. Adjusting abutments with diamond bur.
Figure 14. Fabricating temporary (Visalys Temp [Kettenbach LP]).	Figure 15. Completed temporary.
Figure 16. Postoperative check.	Figure 17. Excellent soft-tissue contours.
Figure 18. Framework on model.	Figure 19. Abutments in place.
Figure 20. Completed case.	Figure 21. Final panoramic radiograph of completed case.

The final restoration was delivered 2 weeks later (Figure 20). Occlusal adjustment was carried out using articulation film and a fine diamond bur. The occlusal surfaces were then polished with ceramic polishing discs (Axis Dental). The abutment screws were all retightened to 30 Ncm, and the access holes filled with Teflon tape prior to final cementation. Fynal (DENTSPLY Caulk) was used to cement the restoration, allowing the option for retrieval in the future if necessary. A postoperative radiograph was taken (Figure 21) to assure all cement was removed and restorations were completely seated. The patient was followed up at one-week post-delivery, and then at a 6-month recall appointment.

IN SUMMARY
With proper presurgical and restorative planning, along with a predictable implant system, it is possible to transition patients from a failing natural dentition to a healthy implant-supported dentition with a minimal amount of disruption to their lives. The use of cross-arch stabilization adds to the predictability of this treatment modality. When implants are stabilized at initial placement, by splinting and utilizing the widest anterior-posterior distribution of the implants, they are able to resist the critical degree of micromovement at the bone-implant interface5 that could be detrimental to the outcome of the case. This, according to the literature, is between 50 and 150 µm of sliding movement. The ability to immediately load a restoration and microstimulate the implant-bone interface below the critical threshold can actually aid the action of osseointegration.⁶ By using the combination of implants designed for immediate load and fixed interim restorations, a predictable and expedient treatment was carried out with a very high level of patient satisfaction.

This case demonstrates the type of dentistry that can change lives. It also shows how we can meet the needs of patients can be satisfied by providing predictable, long-lasting rehabilitation in less time than ever before possible.

References

1. Skoff P. We have lost our patience as a society. Huffington Post. November 8, 2012. huffingtonpost.com/pam-skoff/we-have-lost-our-patience_b_2097229.html. Accessed February 23, 2015.
2. Tan WL, Wong TL, Wong MC, et al. A systematic review of post-extractional alveolar hard and soft tissue dimensional changes in humans. Clin Oral Implants Res. 2012;23(suppl 5):1-21.
3. Östman PO. Direct Loading of Implants [paper]. Gothenburg, Sweden: Sahlgrenska Academy; 2008.
4. Chu SJ, Salama MA, Salama H, et al. The dual-zone therapeutic concept of managing immediate implant placement and provisional restoration in anterior extraction sockets. Compend Contin Educ Dent. 2012;33:524-534.
5. Tarnow DP, Emtiaz S, Classi A. Immediate loading of threaded implants at stage 1 surgery in edentulous arches: ten consecutive case reports with 1- to 5-year data. Int J Oral Maxillofac Implants. 1997;12:319-324.
6. Linkow LI, Glassman PE, Asnis ST. Macroscopic and microscopic studies of endosteal bladevent implants (six month dog study). Oral Implantol. 1973;3:281-309.

Dr. Schlesinger graduated from The Ohio State University College of Dentistry in 1996. After receiving extensive training in implantology and complex dentistry at the Veteran’s Administration Medical Center San Diego (VAMC) and at the VAMC Los Angeles, he maintained a private practice in San Diego for 14 years. He is currently the chief operating officer at OCO Biomedical in Albuquerque and lectures worldwide on implantology. He can be reached via email at chuck@ocobiomedical.com.

Disclosure: Dr. Schlesinger is the COO of OCO Biomedical.