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Full Mouth Rehabilitation Process using Non-
submerged Type ImplantEom Seung-ilDirector, Busan World Dental Clinic
Case report
The patient almost had edentulous jaw and the teeth supporting RPD was separated from the extraction sockets.
The patient has used denture for 6 year. Figure 2 and 3 shows very interesting cases that the abutments weresupported by the extraction sockets.
The patient strongly wanted the restoration of prosthetic implant considering chewing efficiency and appearance.
Two treatment methods were suggested: an implant supported overdenture that a total of 4 each implant is
placed to the anterior region of maxillary and mandible; a fixed prosthesis with 7 to 8 implant placement. The
fixed prosthesis was selected considering patients age in his late 40s and psychological burden.
Fig. 1. Preoperative
radiography. The bonequality and volume showed
the moderate condition for
the implant placement in a
whole.
Fig. 2 and 3. The RPD used before procedure. The retention and
stability of RPD was secured by the abutment which was maintainedby the inside of extraction sockets.
Fig. 4. Before the main implant
procedure, mini-implant was
placed to the anterior of
maxillary and mandible for thetransitional denture to be used
during healing period.
Fig. 5 and 6. The impression was taken under the intraoral placement
of temporary implant. Then the metal splint was made on the upper
part of temporary implant of working cast.
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Fig. 7. The metal splint was intra-
orally adhered using resin cement.
The head of temporary implant
projected to the upper part of metal
splint was removed by bur. The height
of metal splint should be 4mm or more
for securing appropriate retention and
stability.
Fig. 8. After scraping out the inside of transitional
denture, relining on the upper part of metal splint
was made using soft relining material. Firmly
maintained through the connection with temporary
mini-implant, the metal splint improves the
retention and stability of upper denture and extends
the life of temporary implant during healing period.
In addition, the metal splint helps to reduce the
transmucosal loading imposed to the main implant
to be placed to the posterior region.
Fig. 10. Selection of implant
suitable for the bone width and
placement to mandible.
Fig. 9. A non-submerged type
implant placement to the
posterior region of maxillary.
Fig. 11. Following the connection of
solid abutment to the maxillary and
mandible 3 months and 2 months
after implant placementrespectively, the anterior temporary
implant and metal splint was
removed. A temporary fixed
prosthesis was made on the upper
part of solid abutment.
Fig. 12. Temporary fixed prosthesis Fig. 13. Mini-implant (MDL 2
x 13mm) was placed to the
anterior of mandible for
additional support.
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Fig. 14 and 15.
Impressionmaking for whole
maxillary and
mandible wasmade 2 months
after the
placement of
mini-implant.
Fig. 16 to 19. The recordbase was made on the
working cast using GC
pattern resin. The record
base acts as the reference
point of the
determination of
intraoral verticaldimension of occlusion
and taking centric
position.
Fig. 20 and 2. Taking vertical dimension of
occlusion and centric position using record base.
Fig. 22. Mounting the working cast of maxillary
and mandible on the semi-adjustable articulator.
Fig. 23 to 25. The wax-up was primarily made. The canine protected occlusion was selected as
occlusal scheme.
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Fig. 26. Drawing of an circular arc on the occlusal
analyzer to form a appropriate plane of occlusion. The
plane of occlusion was formed using the crossing of
anterior and posterior circular arc as a reference point.
Fig. 27 to 29.The occlusion plane completed on the wax-up.
Fig. 30 and 31.
Marking proper
positions ofbuccal, lingual
cusp, central fossa
of lower teeth on
the wax-up.
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Fig. 32 to 38. Evaluation of the
required elements such as the length
of teeth, midline, occlusal scheme,
positional relationship betweenteeth, vertical dimension of
occlusion, and centric position
following intraoral test of wax-up.
Fig. 39 to 41. Evaluation of elements as the midline, plane of occlusion, length of
teeth during the intraoral insertion of wax-up.
Fig. 42 and 43. Confirmation of proper formation of vertical
dimension of occlusion through the evaluation of the tension
level of facial muscle, pronunciation, freeway space, and several
facial reference points.
Fig. 44. Once more taking of the
centric position on the wax-up
using gauge.
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Fig. 45 to 48. Completion of the
wax-up using newly taken centric
position. Making a jig with acrylic
resin coating on the upper part of
completed wax-up. The jig greatly
helps to coat porcelain due to itsaccurate reproducibility of
completed occlusal plane, cusp
angle, and the size of occlusal
surface.
Fig. 49 to 52. Making an index jig
on the completed wax-up using
putty impression material. This
index jig is referred to theporcelain depth and correct teeth
position in making the frame
work of definitive restoration.
Fig. 53. A cut back process was
made on the wax-up using
index jig.
Fig. 54. The completed wax-up
for making framework.
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Fig. 55. Adhesion of the sprue to wax-up Fig. 56. The completed
framework of maxillary and
mandible.
Fig. 57 and 58. Inspection of the fitness with the intraoralinsertion of completed framework.
Fig. 59. The framework wasmade to maintain the cement
and the fit checker was used to
evaluate the inside fitness.
Fig. 60 and 61. Following thefitness evaluation, the bite was
taken through the final
evaluation of vertical
dimension of occlusion and
centric position (Futar D
Occlusion).
Fig. 62. The porcelain build-upprocess on the upper part of
mandible using jig.
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.
Fig. 63. The occlusal surface of
completed definitive restoration
The size of occlusal surface is
smaller than natural tooth and
the cusp angle is very flat. This
was designed to protect
excessive lateral pressure on the
implant.
Fig. 64. The porcelain build-up
process on the framework of maxilla
based on the completed mandibular
porcelain.
Fig. 65 and 66. Evaluation of the proper formation of canine protected occlusion using articulator. Themaxilla is in the state of bisbaque: the pre-stage of the completion of porcelain.
Fig. 67 to 71. The occlusal adjustment was preformed with the intraoral insertion following the final
evaluation of elements in connection with the appearance and functions.
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Fig. 72 to 74. The delivery of definitive prosthesis.
Definitive restoration for maxillary and mandible was made as one-piece type. Due to the mandibular
flexure, the anterior and posterior region of mandible are sometimes separately fabricated. Otherwise, key &
keyway are attached between front and molar tooth to minimize the transmission of the movement ofmandibular posterior region.
Fig. 75. The panoramic viewof completed definitive
restoration.
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The success and failure of implant applied full mouth rehabilitation depends on how we properly applied the
required elements of prosthesis.
Under the situation without natural teeth, it was difficult to resemble its original state as closely as possible.
Another problem lay in how fast the patient adapted to new fixed prosthesis because he had used the RPD for a
long time.
1. Why we used the temporary mini-implant?
The temporary mini-implant was placed to the anterior of maxillary and mandible to minimize the pressure by
denture after the main implant placement. The metal splint was also prepared to minimize the movement of
transitional denture. The better method is to make temporary fixed prosthesis following the implant placement
between the spaces of main implants; we had no choice but to take other method because this case had no
sufficient spaces for the enough number of temporary implant placement to make fixed prosthesis between main
implants.
2. How many implant placements are required to the full mouth rehabilitation in case of edentulous jaw?
A total of 8 to 10 and 6 to 8 implant placements are generally needed for the maxilla and the mandible
respectively. However, the number can be adjusted in accordance with the condition of bony quality. It is
desirable to place the implant to the posterior region rather than anterior region as practicable as possible. This
may be the attempt to minimize the aesthetical loss caused by the implant placement to the anterior region.
3. How many units consist of the restoration for desirable full mouth rehabilitation?
In case of maxilla, one-piece restoration is desirable for the rehabilitation due to it splint effect if there is no
problem with implant path.
If there is difficulty in dental technology, key & keyway(precision attachment) is attached between anterior and
posterior region to provide the convenience of dental processing. The opening and closing of mouth by
mandible generates the difference of area in posterior region (mandibular flexure). The following methods may
be applied to the mandible to allow the movement of posterior region: to divide each anterior and posterior
region into three equal parts; to attach key & keyway (semi-precision attachment) between anterior and posterior
region; to attach key & keyway(semi-precision attachment) to the middle of mandible.
4. What material is used for the posterior occlusal surface?
In case of the formation of metal occlusal surface in the posterior mandible, it is desirable to cover the porcelainto avoid the exposure of metal through laughing laud or speaking. The fracture of porcelain can be prevented
by making metal occlusal surface on the opposing posterior maxillary.
In case both occlusal surfaces are made of porcelain, it is easy to repair poor occlusion while the sound touching
each other during mastication may generate the sense of being offended. This phenomenon generally happenswhen vertical dimension of occlusion is higher than allowed freeway space. This can be settled by the intraoral
adjustment of occlusion if the difference is small. However, all porcelain should be removed and repeat the
porcelain build-up process from the very first if the difference is big. Setting up of vertical dimension of
occlusion is important to that degree.
5. What occlusal scheme should be set for the full mouth rehabilitation?Likewise the natural teeth, the canine protected occlusion should be prepared for the protection of posterior teeth
when guiding if the implant is placed to the canine region. If this occlusal scheme is difficult due to the position
of implant placement, the occlusal morphology with anterior group function can be made. It is desirable to makeguidance in the anterior region to minimize the occurrence of the possible occlusal problems in connection with
implant.
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