Predictable prosthetic space maintenance during staged complete-mouth rehabilitation

CLINICAL REPORT Predictable prosthetic space maintenance during staged complete-mouth rehabilitation Abdulaziz AlHelal, BDS, MS,a Sarah Bukhari, BDS,b Mathew T. Kattadiyil, BDS, MDS, MS,c Rami Jekki, DDS, MS,d and Ankur Dahiya, BDS, MDS, MSDe Complete-mouth rehabilitaABSTRACT tion is a complex treatment that Staged complete-mouth rehabilitation to accommodate a patient’s financial constraints during requires significant time and the course of treatment is presented. Clear acrylic resin added to the anterior cameo surface of the commitment from both patient maxillary fixed complete denture (FCD) served as a space maintainer. The restoration of the and clinician. The keys to sucmaxillary FCD addressed the patient’s chief complaint. By adding the space maintainer, supracessful complete-mouth rehaeruption of mandibular anterior teeth and encroachment of the prosthetic space, which could have resulted in additional treatment, was avoided. During the second stage of the complete-mouth bilitation are detailed treatment rehabilitation, zirconia restorations were used to restore the mandibular arch to the maxillary planning and complete control FCD after straightforward removal of the space maintainer. This allowed a smooth transition after a of the treatment.1,2 Higher delay in treatment without having to modify the previous treatment. (J Prosthet Dent 2017;-:---) treatment costs can be a primary reason for patients to refrain from seeking compreCAM) interim restorations.27,29-33 This clinical report hensive dental care.3-6 The cost of dental care can be a demonstrates a reversible cost-effective approach with barrier to the consent for dental services that affects bea staged complete-mouth rehabilitation involving a tween 30% to 61% of the population.7 maxillary fixed complete denture (FCD) opposing a A change that usually occurs in complete-mouth restored worn dentition. rehabilitation is in occlusal vertical dimension (OVD).8 Restoring patients with loss of posterior support can CLINICAL REPORT be clinically challenging because these patients tend to 9-11 have reduced OVD. Sometimes with decreased OVD A 61-year-old white woman sought care at the Loma the interocclusal space is insufficient, which can further Linda University School of Dentistry, noting, “I am tired complicate the rehabilitation process.10-14 When of having my upper implant bridge repaired, but I cannot restoring such patients, the use of homogenous antagafford to have all my teeth fixed at the moment” onistic restorative surfaces is a consideration and is (Fig. 1A). Her dental history revealed that she recently recommended to reduce wear.11,15-21 had 6 dental implants (NobelSpeedy Groovy; Nobel When patient finances become an unexpected factor Biocare) placed in her completely edentulous maxillary that delays treatment, long-term interim restorations are arch (Fig. 1B) and 3 dental implants in her partially often indicated.11,22-28 However, complications might edentulous mandibular arch (NobelReplace Tapered; develop with these restorations because of material Nobel Biocare). A fractured maxillary interim FCD degradation, even with improved computer-assisted opposing a mandibular arch with teeth having moderate design and computer-assisted manufactured (CADto severe attrition (Fig. 1C) resulted in reduced OVD. a Faculty, Department of Prosthetic Dental Sciences, College of Dentistry, King Saud University, Riyadh, Saudi Arabia. Graduate student, Advanced Specialty Education Program in Prosthodontics, School of Dentistry, Loma Linda University School of Dentistry, Loma Linda, Calif. Professor and Director, Advanced Specialty Education Program in Prosthodontics, Loma Linda University School of Dentistry, Loma Linda, Calif. d Assistant Professor, Advanced Specialty Education Program in Prosthodontics, School of Dentistry, Loma Linda University, Loma Linda, Calif. e Private practice, Austin, Texas. b c THE JOURNAL OF PROSTHETIC DENTISTRY 1 2 Volume - Issue - Figure 1. A, Intraoral frontal view showing fractured interim fixed complete denture. B, Occlusal view of maxillary arch showing preexisting implants. C, Intraoral view of mandibular remaining natural dentition. Figure 2. A, Intraoral frontal view of definitive wax trial prosthesis with maxillary milled titanium FCD framework. B, Casts view showing planned prosthetic space for future mandibular anterior crowns before FCD processing. FCD, fixed complete denture. After replacing the repaired interim FCD, various treatment options were discussed. The decision was made to fabricate a definitive FCD first to replace the interim maxillary FCD and to restore the mandibular arch later to accommodate financial constraints.34 To maintain OVD and planned prosthetic space until the patient was ready to proceed with the definitive treatment for the mandibular arch without compromising restorative outcome, a clear acrylic resin layer was added to the definitive FCD opposing the mandibular teeth. Stage 1 A maxillary implant level impression was made with open tray impression copings and intraorally splinted with light-polymerizing composite resin (Filtek Supreme Ultra Universal Restorative; 3M ESPE). Maxillary and mandibular casts were poured in Type IV dental stone (Resin Rock; Whip Mix Corp) with a simulated soft tissue material (GI-Mask; Coltène) around the maxillary implant analogs. An implant screweretained flangeless maxillary occlusion rim was fabricated to capture maxillomandibular relations at the proposed OVD. After the definitive casts were mounted, the teeth were arranged on the trial denture to achieve mutually protected articulation. After intraoral THE JOURNAL OF PROSTHETIC DENTISTRY assessment of the trial maxillary FCD, a putty index (Lab putty; Coltène) was generated from the wax patterns. An optical scanner (D900L; 3shape) was used to scan the maxillary cast and trial tooth arrangement to design and fabricate a milled titanium framework for the maxillary FCD (NobelProcera; Nobel Biocare). The metal framework at the trial placement was placed intraorally, and a 1-screw test and radiographs were used to confirm fit.35 The maxillary tooth arrangement was transferred to the metal framework using the previously generated putty index (Fig. 2), and the new wax trial prosthesis was clinically evaluated. At this phase of treatment, the trial maxillary FCD was placed, and the mandibular anterior teeth were then restored with composite resin (Filtek Supreme Ultra Universal Restorative; 3M ESPE) (Fig. 3A). The OVD and the mandibular occlusal plane were not changed. A new mandibular impression and maxillomandibular relation records were made opposing the trial maxillary FCD. The new mandibular cast was duplicated (Capsil; Great Lakes Orthodontics). Both duplicate casts were mounted on the same articulator from the interocclusal records opposing the same trial FCD. The FCD was processed in a conventional manner AlHelal et al - 2017 3 Figure 3. A, Intraoral view of restored mandibular anterior teeth at interim treatment stage. B, Cast frontal view showing mandibular wax patterns opposing processed definitive maxillary fixed complete denture. C, Cast view showing wax patterns of future mandibular anterior crown designed at transitional treatment stage. Figure 4. A, Cameo surface of maxillary processed FCD before modification. B, Occlusal view of modified FCD with clear acrylic resin as prosthetic space maintainer. Interproximal acrylic resin was removed through to facial surface. Clear acrylic resin was added and contoured to create palatal anatomy to blend with modified FCD. FCD, fixed complete denture. in heat-polymerized acrylic resin (Lucitone 199; Dentsply Sirona) (Fig. 3B). On one of the mandibular casts, a wax pattern was made for the mandibular arch opposing the processed FCD for the second stage of treatment (Fig. 3B, C). The other mandibular cast was attached to the articulator at the same proposed OVD. Clear acrylic resin (Jet Tooth Shade Powder; Lang Dental Manufacturing Co) was injected onto the cameo surface of the maxillary FCD palatal to the anterior teeth, and all excursive mandibular movements were performed on the articulator to establish ideal occlusal contacts. Excess acrylic resin was carefully removed from the palatal incisal edges of the anterior teeth and the interproximal areas to provide improved palatal form. The maxillary FCD was then immersed in warm water (43 C) in a pressure vessel at 200 kPa for 10 minutes to achieve complete polymerization of the added resin (Fig. 4). The FCD was then remounted, and the final finishing and polishing were completed (Fig. 4B). The definitive prosthesis was inserted intraorally (Fig. 5A). The fit of the prosthesis, occlusion, esthetics, and phonetics were AlHelal et al reconfirmed, and occlusal screws were tightened according to the manufacturer’s recommendations. The screw access holes were sealed with composite resin (Filtek Supreme Ultra Universal Restorative; 3M ESPE). A mandibular acrylic resin interim removable partial denture was placed to replace missing posterior teeth. Stage 2 After 12 months (Fig. 5B), the patient returned for completion of treatment. The existing mandibular natural teeth were prepared, and the clear acrylic resin was removed from the FCD (Fig. 5C). Definitive impressions for the mandibular arch were made for both prepared teeth and uncovered implants. New maxillomandibular relation records were made opposing the definitive FCD, and the new mandibular definitive casts were mounted on the same articulator. Mandibular interim restorations were fabricated based on the previously made wax patterns (Protemp Plus Temporization Material; 3M ESPE) and cemented with interim cement (TempBond Temporary Dental Cement; Kerr Corp). THE JOURNAL OF PROSTHETIC DENTISTRY 4 Volume - Issue - Figure 5. A, Intraoral frontal view of prosthetic space maintainer in occlusion, preventing supraeruption of opposing anterior teeth and providing harmonious contact with all excursive mandibular movements without esthetic compromise. B, Occlusal view of maxillary modified fixed complete denture at 12 months. C, Occlusal view after removal of clear acrylic at provisionalization stage of prepared mandibular anterior teeth. Figure 6. A, Intraoral occlusal view of definitive mandibular prosthetic treatment. B, Intraoral frontal view of definitive complete-mouth rehabilitation. Definitive milled zirconia (Multi-Layered Zirconia; Talladium) restorations were fabricated for the mandibular arch and cemented (Fig. 6A). The occlusion was adjusted and polished as needed (Fig. 6B). Oral hygiene instructions were given, and follow-up recall visits were scheduled. DISCUSSION Complete-mouth rehabilitation is clinically challenging, and the extensive nature of the treatment makes it unappealing for patients on limited incomes.3-7 This clinical report describes one such situation in which patient expressed concerns regarding expenses associated with her preferred treatment option. A staged approach was recommended to the patient to allow time for her to begin and complete the second stage of treatment while addressing her chief complaint immediately. Interim modification in the form of clear acrylic resin was placed on the maxillary FCD to maintain prosthetic space at the planned OVD and the integrity of the remaining dentition. Using this staged approach, the long-term outcome was not jeopardized because of the delay in treatment completion. Furthermore, complications were avoided such as the need for THE JOURNAL OF PROSTHETIC DENTISTRY significant recontouring of the maxillary FCD, which could have affected treatment outcome.9,24 The secondary adjunctive and interim approach helped maintain OVD, occlusal plane, and prosthetic space, preventing the potential supraeruption of mandibular anterior teeth and avoiding future need for excessive tooth preparation, endodontic therapy, or crownlengthening surgery.9 Her OVD was restored and maintained at the initial phase of treatment, which served as a reversible and hence transitional prosthetic modification. Interim phase modification to the FCD could have been considered a definitive treatment if the patient had not returned. SUMMARY A staged approach is described as an innovative way to address long-term delay in complete- mouth rehabilitation. 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