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