Drs. Iham Gammas and Haroutioun Kotchinian collaborate for extra predicable surgical and restorative outcomes
This 77-year-old retired male sought dental therapy as a result of issue chewing and poor esthetics attributable to lacking enamel. His medical historical past revealed hypertension, an allergy to penicillin, and present remedy with Losartan. His dental historical past indicated an absence of oral hygiene leading to tooth decay and important tooth loss. Earlier dental remedies included fillings, extractions, and dentures, however the ill-fitting dentures precipitated discomfort whereas consuming, talking, and smiling.
Throughout the scientific examination, the affected person displayed a number of lacking, decayed, and damaged enamel, together with extreme put on on his remaining enamel. His excessive lip line and comparatively good positioning of the remaining anterior enamel relative to his lips had been famous.
A complete therapy plan was developed, which consisted of the next steps:
- Extraction of enamel Nos. 3 and 11.
- Placement of eight Ditron dental implants within the decrease arch to help a full-arch mounted dental prosthesis.
- Placement of three Ditron implants within the higher arch for single implant restorations.
- Preparation of the higher arch by Dr. Kotchinian and closing impression incorporating the three dental implants.
- Higher arch fabrication utilizing exocad software program to merge preoperative full smile photographs with the ultimate impression, customizing the smile line based mostly on the affected person’s extraoral options.
- Supreme restoration of the higher arch 2 months after surgical procedure.
Surgical process — Dr. Iham Gammas
It is a case of teamwork, as I carried out the surgical side, and Dr. Kotchinian accomplished the restoration. We steadily do a lot of these full arch rehabilitations in tandem. The affected person offered with an entire denture for the decrease arch and higher arch the place many of the enamel had been salvageable apart from enamel Nos. 3 and 11. The plan was to revive to 1st molar occlusion. Utilizing the CBCT as a diagnostic, we had been in a position to plan the case with extra prosthetic predictability because it acted as one other a part of the ultimate blueprint for the case.
I plan all circumstances utilizing a CBCT scan-based planning software program. For my surgical procedures, I love to do full thickness incisions and flaps to completely expose the buccal and lingual surfaces of bone. This fashion I get really feel for the surgical website, unrestricted views, and in the end, a extra fine-tuned placement of implants. That is particularly necessary in thinner ridges. I’m additionally in a greater place to control the delicate tissue and am extra ready for a possible want for bone grafting. If a deliberate implant is in proximity to the psychological foramina, I like to reveal as much as the foramina and maintain a word of it. A pleasant piece of armamentarium that can make full-arch surgical procedures simpler is the usage of OptraGate by Ivoclar. This latex-free lip and cheek retractor permits for all the things buccal to the surgical website be extra out of the way in which all through the process. This gives one much less challenge to wrestle with and will increase the possibility that the clinician received’t nick lips or different tissue inadvertently.
The implants had been all positioned freehand. The position of the higher arch had enough landmarks to position the implants in a simple vogue. The position of implants 3 and 11 had been quick placements. Relying on surgical approach and implant design, I’ve discovered that quick implant placement may be finished generally. Implant 3 was positioned within the intraseptal bone, and 11 was positioned partaking the lingual plate to permit for a screw-retained crown with an entry gap on the cingulum. I steadily use Versah® Densah® burs to optimize the osteotomy. Even when I’ve enough bone width, I could use a Densah drill as a closing drill earlier than implant placement.
When grafting, I practically all the time use a placental membrane to cowl the bone graft. I’ve been utilizing BioXclude® (Snoais Medical), a resorbable placental membrane, for years, however there are different competing merchandise to select from. They supply ample quantities of development components and have antimicrobial exercise, all in a handy bundle. It makes for an final result with a better likelihood of success. For websites 3 and 11, I used a particulate cortical allograft to fill within the remaining socket, then tuck the membrane beneath the gingival margins and suture the flaps down to carry all the things in place.
For the decrease arch, I used a couple of landmarks and measurements to get the implants within the correct positions and trajectory. First, I used the CBCT as a place to begin to find out the spacing of implants in positions – 19, 20, 21, 23, 26, 28, 29, and 30. I take advantage of a Castroviejo caliper to make sure correct spacing when I’m putting multiple adjoining implant. I then begin with preliminary drill factors and are available again and recheck spacing. For the trajectory, I make sure that the drilling is within the route of the opposing dentition. For instance, on this case, I stored the anterior implant trajectories consistent with lingual of the maxillary enamel. This may be confirmed as drilling proceeds with paralleling pins and having the affected person slowly occlude. To maintain the implants parallel to one another, I take advantage of the midline of the face as a sort of fiduciary place, then maintain the drill straight on whereas transferring into the posterior osteotomies. As I transfer up in drill diameter, I begin once more with the anterior osteotomies then go posterior. I’d carry on rechecking and correcting the parallelism, if wanted, as I’m going on. One other approach is to position a parallel pin within the middle of the ridge on the midline and use that to verify parallelism.
On this case, I used Ditron Final™ implants for the next positions — 4.2×11.5 for all of the decrease implants, 5×8 for 3 and 14, and 4.2×16 for 11. I used this implant for the preliminary stability the threading design gives and due to the coronal convergence of the implant. This permits for much less bone pressure on the neck, a form of platform swap, and anecdotally extra delicate tissue thickening.
For suturing, my go-to is Glycolon™ 5-0 by Resorba®, a PGA-PCL copolymer resorbable monofilament suture that often resorbs in round 3-4 weeks. I discover it has enough tensile power and fewer likelihood to retain plaque buildup.
Restorative higher arch — Dr. Haroutioun Kotchinian
The higher arch fabrication was achieved utilizing exocad software program to merge preoperative full-smile photographs with the ultimate impression, customizing the smile line based mostly on the affected person’s extraoral options. Supreme restoration of the higher arch was famous 2 months after surgical procedure. When seeking to restore a full arch for a affected person, there are various totally different faculties of thought from Kois, Spear, Pankey, and past. Lots of them have comparable ideas, however use totally different terminology. My background got here from Spear and the Esthetic, Operate, Construction, Biology (EFSB) workflow. On this case, I spent more often than not within the Esthetic part to find out his superb central show, central angulation, midline location, gingival ranges, and buccal hall.
He had no practical habits that we wanted to be involved about. No jaw ache was current at present or up to now, and no TMD. He did have put on, however we attributed that to progressive tooth loss over time, and the stress that the remaining enamel needed to incur because of that. When it comes to Construction, we selected to make use of porcelain-fused-to-zirconia (PFZ) crowns as a result of they’re extremely esthetic, and we want not fear about metallic exhibiting over time. Additionally PFZ crowns typically have larger worth than E.max® crowns as they let much less mild journey by way of. This worth resulted in a extra pure search for our affected person as his pure enamel had been much less translucent. So long as there may be satisfactory thickness of the porcelain, chipping is changing into extra uncommon. Lastly, addressing the affected person’s biology, he had satisfactory bone and probing across the enamel for long run success. His gums had been barely pink, however might be managed by way of common prophylaxis. Lastly, his enamel didn’t want endo as there have been no massive caries, and our preparation was deliberate as conservative/regular.
For circumstances similar to this affected person, we all the time take earlier than photographs at relaxation, full smile, and intraoral.
In prepping the case, I first took a preop impression of his present enamel, as a result of I favored the place of tooth No. 8 relative to his face. For an older affected person, exhibiting about 70%-80% tooth at a smile is satisfactory particularly for our male sufferers. He didn’t need to be too “toothy.” On this explicit case as a result of we had been going to stage the higher and decrease restorations, I merely took a blue-bite impression for his eventual temporaries. I prepped the case doing my greatest to prep every space of the enamel on the identical time, to take care of superb preps, and angulations. I prep on this order — incisal, buccal, mesial, distal, and lingual. Then I polish utilizing a tremendous diamond, and further polish with a sluggish velocity sprucing cup. Lastly, I gently go a tremendous diamond 859L bur alongside the margins to open the gums barely and take away any unsupported enamel.
In making ready for my closing impression, I first fabricate the temporaries, utilizing them as customized retraction caps. I positioned Hemoban (Dentsply Sirona) and GingiTrac® (Centrix) on the enamel and positioned the temporaries over prime of them. This permits me to retract the gums and management bleeding. Though packing twine is the best, I discovered in my expertise that this helps save time and supply satisfactory retraction for impression.
For the implants, we used open-tray impression copings. A PA was taken previous to the ultimate impression. For the ultimate impression we use Aquasil® mild physique and heavy physique in a knockout patented impression tray.
Following the appointment, all this was despatched to the lab which digitized the impressions. Utilizing exocad, they had been in a position to place the total smile photograph over the preop and prepped scan. This permits us the liberty to design his case for his face with out having him within the chair for a number of periods with temporaries. I often obtain an exocad hyperlink which I can conveniently open on my iPhone®, and analyze for all of the parameters we talked about earlier than. Then I give my suggestions to the lab, they usually make the required modifications and ship me a hyperlink for closing approval.
Once we inserted his higher arch, there was no guessing as to the way it was going to look. We knew the lengths we wanted and the areas within the buccal hall that wanted to be crammed, due to our digital design. The affected person was very happy with this step, and was again to Dr. Gammas for his mounted hybrid.
Restorative decrease arch — Dr. Iham Gammas
The prosthesis was fabricated for the decrease implants utilizing conventional analog methods, together with a closing impression, wax chew, and creation of a PMMA try-in. The complete-arch mounted dental prosthesis was fabricated out of zirconia, and was delivered 4 months after surgical procedure. The affected person was monitored throughout the therapeutic section, with changes made to the prosthesis as mandatory.
The complete mouth rehabilitation yielded profitable outcomes for this affected person, enabling him to regain his chewing operate, speech, and esthetics. He reported improved consolation and satisfaction with the brand new prosthesis, which carefully resembled pure enamel in each look and performance. The affected person obtained steerage on correct oral hygiene practices and was suggested to schedule common follow-up visits for ongoing upkeep and monitoring.
In conclusion, full mouth rehabilitation following enamel extraction can considerably improve the standard of life for sufferers with intensive dental points. Using dental implants and bone grafting gives stability and sturdiness for mounted dental prostheses, restoring important features and esthetics. Whereas reimbursement limitations could exist in our neighborhood for such procedures, the utilization of a digital workflow permits for correct enamel design with out the necessity for conventional wax-ups and lab-fabricated provisionals, providing a optimistic expertise for sufferers whereas guaranteeing the sleek operation of our dental workplace.
